PAINLESS CHILI: I 



EUTO 



BHn 




', ... I : L 




CARL HENRY D 




Class __S-jiX3_2- 
Book Jl3_ 



Copyright^ 



CORfRIGHT DEPOSm 



PAINLESS CHILDBIRTH 

EUTOCIA AND 

NITROUS OXID-OXYGEN 

ANALGESIA 



Painless Childbirth 

Eutocia and 

Nitrous Oxid-Oxygen Analgesia 



BY 

CARL HENRY DAVIS, A.B., M.D. 

Associate in Obstetrics and Gynecology, Rush Medical College 

in affiliation with the University of Chicago. 

Assistant Attending Obstetrician and Gynecologist 

to the Presbyterian Hospital, Chicago. 




CHICAGO 

FORBES & COMPANY 

1916 






COPYRIGHT, 1916, BY 
FORBES AND COMPANY 







M 24 1 9? 6 



CI.A4205U1 



With tender memories of my 

mother and her patience in suffering 

this little book is dedicated 

to 

MOTHERHOOD 



CONTENTS 

CHAPTER PAGE 

I Introduction 13 

II Development of Anesthetics ... 20 

III The Chemicals and Their Effects . 28 

IV Nitrous Oxid and Oxygen in American 

Obstetrics 39 

V Objections to Twilight Sleep ... 43 

VI Advantages of Nitrous Oxid-Oxygen 

Analgesia 49 

VII Eutocia 55 

VIII Obstetrical Facts and Statistics . . 62 

IX Unnecessary Mortality .... 72 

X Nitrous Oxid-Oxygen Analgesia in 

Obstetrics 87 

XI Technic of Administering Nitrous 
Oxid-Oxygen Analgesia in Normal 

Obstetrics 101 

XII Eeasons for Failures in Securing Anal- 
gesia 114 

XIII Nitrous Oxid- Air or Nitrous Oxid- 

Oxygen 118 

XIV A Study of 154 Consecutive Deliveries 121 
XV Conclusions 130 



DEFINITIONS 

Eutocia (u-to'-ke-ah) (cA well; t 6kos, 
childbirth). An easy natural delivery. 
Eutocia should be the desire of every 
mother and the aim of every physician. 

Analgesia (an-al-je'-ze-ah) (d priv.; 
dAyos, pain). Insensibility to or absence 
of pain. In the use of nitrous oxid and 
oxygen the physician produces analgesia 
during the uterine contractions without 
interfering in any way with the normal 
mechanism of labor. 

Amnesia (am-ne'-se-ah) (afivrjala, for get- 
fulness). Defect of memory. Loss of 
memory for words. The aim in Dammer- 
schlaf is to obliterate the memory of pain. 
During labors conducted under scopolamin 
and morphin or narcophin, the patients will 
often cry out as loudly during the uterine 
contraction and complain of as much pain as 
those who have no anesthetic, but in the 
successful cases they will not remember this 
after the delivery of the child. 



PART I 
PAINLESS CHILDBIRTH 



The belief that pain is an inevitable 
accompaniment of labor has reconciled 
mothers to endure it, while the joy of 
successful motherhood has caused them to 
forget it. There is, however, no logical 
reason why women should suffer during 
labor. 



PAINLESS CHILDBIRTH 

CHAPTER I 

Introduction 

If labor is a purely physiological process 
it should be as free from pain as are other 
physiological processes. Yet if we are to 
believe the King James version of Genesis, 
Eve was undoubtedly the first woman to 
suffer the pangs of childbirth. Nevertheless 
there are many reasons for believing that 
the extreme suffering of labor is a penalty 
of civilization and artificial refinement. 

Attempts to relieve the pains of labor 
date back to antiquity. Writing on the 
history of anesthetics in midwifery, Sir 
James Y. Simpson says: "The ancients 
appear also to have attempted to relieve the 
pain attendant upon parturition by anes- 
thetizing agents, as we may learn from the 

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PAINLESS CHILDBIRTH 



various Greek writers. Such a practice is 
mentioned by Platus in his Ophelion, and I 
may also quote the following passage. 
Theocritus says: 

" 'For then the daughter of Antigone, 
weighed down with throes, called out for 
Lucina, the friend of women in travail, and 
she with kind favour stood by her, and in 
sooth poured down her whole limbs an 
insensibility to pain, and so a lively boy, 
like to his father, was born.' " 

Further Simpson says: "In the trials 
of the sixteenth century we find many cases 
in which witches were prosecuted for 
attempting to abolish the pains of labor by 
charms and other means. One method that 
was practiced was to hold a sword before 
the patient, who was directed to look at it 
steadily, in the same way that Latina is 
said to have held a palm branch, and 
brought forth Apollo without suffering; an 
attempt at mesmerism in reality. Another 

14 



PAINLESS CHILDBIRTH 



way employed was to hang the husband up 
in the next room by his feet till the labor 
was accomplished." 

Yet it is evident that there was very little 
attention given the suffering of the expect- 
ant mother before the experiments of 
James Y. Simpson, who was knighted by 
Queen Victoria after she had experienced 
painless childbirth. When in 1847 he 
introduced ether and chloroform into 
obstetrical practice there was a storm of 
disapproval. Had it been in the sixteenth 
century there is little doubt but that he 
would have fared as badly as the witches. 
Since God had in his primeval curse said: 
"In sorrow thou shalt bring forth children," 
the religious fanatics, and they were many 
in his day, claimed that it was sacrilegious 
to relieve the pangs of childbirth. But 
Simpson was able to prove by the Bible that 
God had promised on several occasions to 
remove the curse. Furthermore he argues 

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PAINLESS CHILDBIRTH 



that if: "we were to admit that woman was 
as a result of the primal curse, adjudged to 
the miseries of pure physical pain and 
agony in parturition, still, certainly under 
the Christian dispensation, the moral neces- 
sity of undergoing such anguish has ceased 
and terminated. " 

The Labor or Primitive Races 

Much has been said of the painless 
labors of the primitive races. In the diary 
of the Lewis and Clarke expedition under 
the date of August 26, 1805, we find this 
interesting record: 

"One of the women, who had been lead- 
ing two of our pack horses, halted at a 
rivulet about a mile behind, and sent on 
the two horses by a female friend. On 
inquiring of Cameahwait the cause of her 
detention, he answered, with apparent 
unconcern, that she had just stopped to 
lie in, but would soon overtake us. In fact, 

16 



PAINLESS CHILDBIRTH 



we were astonished to see her, in about an 
hour's time, come on with her new born 
infant, and pass us on her way to the camp, 
seemingly in perfect health. The wonder- 
ful facility with which the Indian women 
give birth to their children would seem 
some benevolent gift of nature, in exempt- 
ing them from the pains which their savage 
state would render doubly grevious." 

Engleman tells us that: "Commonly 
labor is conducted most privately and 
quietly; the Indian squaw is wont to steal 
off into the woods for her confinement. 
Alone or accompanied by a female relative 
or friend she leaves the village, as she feels 
the approach of labor, to some retired spot ; 
upon the banks of a stream is the favorite 
spot the world over. The vicinity of water, 
moving water if possible, is sought, so that 
the young mother can bathe herself and 
her child and return to the village cleansed 
and purified when all is over." But while 

17 



PAINLESS CHILDBIRTH 



the labor of the primitive woman was usu- 
ally easy and relatively painless, in the 
presence of some pathological condition her 
agonies often ended in death. 

The Penalty or Civilization 

Civilization with its artificial dress and 
customs has rendered woman more of a 
hot-house product and physically less fit to 
perpetuate the race. Thirty years ago 
Lusk warned us that: "As the nervous 
organization loses in the power of resist- 
ance as the results of higher civilization and 
artificial refinement, it becomes imperatively 
necessary for the physician to guard her 
from the dangers of excessive and too 
prolonged suff ering." 

Among civilized women easy and pain- 
less childbirth is not rare, but most women 
are in labor several hours, and unaided 
endure considerable and often very severe 
pain. The belief that pain is an inevitable 

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PAINLESS CHILDBIRTH 



accompaniment of labor has reconciled 
mothers to endure it, while the joy of 
successful motherhood has caused them to 
forget it. There is, however, no logical 
reason why women should suffer during 
labor. Surgeons will not permit their 
patients to suffer during an operation. 
Suffering, physical or mental, produces 
surgical shock; it increases the danger of 
puerperal complications, and delays the 
convalescence. The suffering can be re- 
lieved and with perfect safety to both 
mother and child. 



19 



CHAPTER II 

Development of Anesthetics 

The development of anesthetics is an 
interesting chapter in the history of medi- 
cine. Sir Humphrey Davy, in 1800, dis- 
covered the anesthetic properties of nitrous 
oxid, and suggested its employment in 
surgery in the following words: "As nit- 
rous oxid, in its extensive operation, seems 
capable of destroying physical pain, it may 
probably be used to advantage during 
surgical operations in which no great effu- 
sion of blood takes place." In 1818, Fara- 
day showed that the inhalation of ether 
vapor produced anesthetic effects similar to 
those of nitrous oxid. Crawford W. Long 
of Georgia, in 1842, used ether to produce 
anesthesia during surgical operations. Two 

20 



PAINLESS CHILDBIRTH 



years later, Horace Wells had a tooth 
extracted while under the influence of nit- 
rous oxid. Morton used ether for surgical 
anesthesia in the Massachusetts General 
Hospital in 1846, and made the first public 
announcement of its use for this purpose. 
In January, 1847, Simpson first used ether 
to produce analgesia in midwifery. Flour- 
ens, in March of the same year, announced 
the anesthetic properties of chloroform, and 
Simpson, in November, read his paper 
entitled, "Notice of a New Anesthetic 
Agent as a Substitute for Sulphuric Ether 
in Surgery and Midwifery." From this 
time there was a rapid development of 
chloroform anesthesia, while after the death 
of Wells little use was made of nitrous 
oxid until after Edmund Andrews, in 1868, 
suggested its use with oxygen. Ten years 
later Paul Bert conducted exhaustive 
experiments to show the safety of nitrous 
oxid and oxygen as an anesthetic. 

21 



PAINLESS CHILDBIRTH 



Development of Obstetrical Analgesia 

Ether and chloroform were in turn advo- 
cated by Simpson, and, since his experi- 
ments, have been used to some extent by 
every physician who has practiced ob- 
stetrics. Following the birth of the late 
King Edward, chloroform a la reine became 
the fashion and analgesia was maintained 
for many hours in large numbers of cases. 
Protheroe Smith, in a letter to Simpson, 
states that he had used the chloroform 
analgesia for as long as twenty-eight and 
one-half hours. Simpson, himself, used it 
for over thirteen hours. But recent experi- 
ments have demonstrated the dangers of 
these anesthetics, and, while chloroform has 
been discarded by many obstetricians, ether 
has been limited to the end of the second 
stage of labor, and therefore only partially 
relieves the suffering. 

Klikowitsch of Petrograd applied nitrous 

22 



PAINLESS CHILDBIRTH 



oxid-oxygen analgesia to twenty-five ob- 
stetrical cases in 1880. He used 80 per 
cent nitrous oxid and 20 per cent oxygen, 
and observed that three or four inhalations 
rendered the uterine contractions painless 
without clouding the consciousness. He 
reported that the uterine contractions were 
often stimulated and that in no case was 
there any diminution in their frequency or 
strength. The following year Winckel of 
Dresden used the nitrous oxid-oxygen 
analgesia in 50 cases, and in his Text-Book 
of Midwifery (translated by Edgar) makes 
the following statement: 

1 'Narcosis by means of laughing gas is 
not dangerous and may be discontinued at 
the will of the parturient woman; it 
mitigates the pain in proportion to the 
intelligence of the person, as stupid persons 
often withstand its influence for a long 
time before its favorable effect is felt. In 
most persons its inhalation produces a state 

23 



PAINLESS CHILDBIRTH 



of intoxication for a short time with a 
tendency to laughter. Women to whom it 
is not administered until the stage of expul- 
sion, can seldom be induced to inhale it 
quietly, while when it is administered in the 
first stage of labor its beneficial action is at 
once felt and extends to the second stage. 
It is especially useful in primipara." 

In speaking of the clinical results 
Winckel says: 

"The pulse of the parturient woman is 
usually slowed considerably by laughing 
gas, but finally reaches its original rate 
again. The child's pulse is also slower in 
8 per cent, but usually it seems to be more 
frequent. The woman's temperature rises 
often several tenths of a degree. At first 
the pupils are somewhat contracted. The 
pains are not the same in strength or dura- 
tion, but are often more frequent and 
stronger, and existing vomiting frequently 
ceases. Klikowitsch and I have both ob- 

24 



PAINLESS CHILDBIRTH 



served aphasia, and once in 50 cases a 
hystero-epileptic attack was caused, and in 
one a real epileptic seizure followed its use, 
but otherwise no bad effects were observed, 
either as regards the mother or the child. 
The oxygen of the blood remains in normal 
combination, while the nitrous oxid prob- 
ably circulates in much looser chemical 
combination in the blood, absorbed by the 
plasma. (Doederlein.) These researches 
should be supplemented by the observations 
of others, and were by no means thought 
conclusive by us, as Doederlein believes. It 
seems to me most practical to get the mix- 
ture from the apothecary, as was formerly 
the case, and that he should be provided 
with rubber bags, which he may fill and 
furnish the physician when needed. In this 
manner the gas might be introduced into 
private practice and would not be monop- 
olized by the clinics. A number of interest- 
ing problems attach to its use, but we 

25 



PAINLESS CHILDBIRTH 



refrain from discussing them. The appa- 
ratus which consists of a rubber bag like a 
pillow, is inconvenient, it must be con- 
fessed, but this is entirely subordinate; in 
abnormally painful labor it is at any rate 
an extremely important remedy." 

But owing to its cost, the impurity of the 
gas secured, the crudeness of the apparatus 
used, and the fact that it was often given 
to the stage of asphyxia, nitrous oxid did 
not come into use at that time. 

In 1902, von Steinbiichel of Gratz first 
suggested the use of scopolamin and mor- 
phin analgesia in obstetrics, and the follow- 
ing year reported its use in twenty cases 
with only one in which the pain was not 
relieved. Gauss of Freiberg made his first 
report in 1906. The method has been tried 
by many physicians with varying degrees 
of success, but due to the long continued 
experiments of Gauss a technic has been 
developed, which, under favorable condi- 

26 



PAINLESS CHILDBIRTH 



tions and in selected cases, gives satisfactory 
results in from 70 to 90 per cent of the 
cases in which the drugs are administered. 
After some twelve years of use, abuse and 
disuse, the use of scopolamin and morphin 
was discovered by the lay press, and the 
women of America were told of this won- 
derful (?) Ddmmerschlaf and painless child- 
birth. Within a few months "twilight 
sleep" became a fad, and the relief of pain 
during labor became the chief problem of 
the average physician who practices 
obstetrics. 



27 



CHAPTER III 

The Chemicals and Their Effects 

While we believe that the early develop- 
ment of the woman, her general condition 
of health, her pre-natal care with its diet 
and exercise, are of prime importance in 
securing eutocia, there are at present two 
important methods of relieving the pain of 
labor. But before discussing their relative 
merits in obstetrical practice, it will be well 
to consider the chemistry, physiology and 
pharmacology, and the toxicology of the 
chemicals used. 

Chemistry 

Nitrous oxid is a colorless, odorless gas 
having a somewhat sweetish taste, which 
was discovered by Priestly in 1772. It is 

28 



PAINLESS CHILDBIRTH 



obtained from the distillation of ammonium 
nitrate. 

Oxygen is a gaseous element which was 
also discovered by Priestly in 1774. It "is 
a permanently elastic fluid, invisable, in- 
odorous, and a little heavier than atmos- 
pheric air." 

Morphin is the chief alkaloid of opium 
and represents its physiological activity. 

Scopolamin is obtained from the dried 
rhizome of Scopola Carniolica, and hyocin 
is an alkaloid derived from the leaves and 
flowering tops of Hyocyamus Niger. They 
are identical in their chemical formulae 
and have the same physiological action. 
(Stevens.) It is stated that many manu- 
facturing chemists dispense both from the 
same stock bottles. 

Physiology and Pharmacology 

Cushny states that nitrous oxid supports 
combustion outside the body, but that so 

29 



PAINLESS CHILDBIRTH 



far as the metabolism of protoplasm is con- 
cerned, it behaves the same as any other 
indifferent gas, since the oxygen is not split 
off from the nitrogen as it is when the oxid 
is exposed to high temperatures outside the 
body. "Nitrous oxid is dissolved in the 
blood exactly as in water. There is no 
chemical combination formed with any of 
its constituents, nor is the hemoglobin 
altered in any respect." He considers that 
the nitrous oxid has a direct effect on the 
central nervous system, although it is indif- 
ferent to other tissues. But, "Bert's and 
Martin's experiments would indicate that 
death occurs not from the direct action of 
the oxid on the respiratory center, but from 
the lack of oxygen, although the depression 
of the center is undoubtedly a contributing 
factor." (Cushny, Textbook on Pharma- 
cology, 1906.) 

"Oxygen gas is necessary to respiration, 
and no animal can live in an atmosphere 

30 



PAINLESS CHILDBIRTH 



which does not contain a certain proportion 
of uncombined oxygen." 

Cushny says that the action of morphin 
on the central nervous system seems to 
consist of a mixture of stimulation and 
depression. In man and most other animals 
the respiration is slowed by morphin. 
Children are very susceptible to opiates. 
Morphin has little direct action on the 
circulation. As a general rule the secretory 
glands are rendered less active. The select- 
ive action of morphin is illustrated in its 
effects on the medulla oblongata, for the 
respiratory centre is paralyzed before the 
centres for cardiac inhibition and vaso- 
constriction are affected to any marked 
extent. 

In large doses scopolamin paralyzes the 
inhibitory terminations in the heart, but in 
therapeutic doses this effect is not observed. 
As a general rule hyocin produces a marked 
sensation of fatigue and drowsiness, and 

31 



PAINLESS CHILDBIRTH 



the patient moves about less and speaks 
less. * 'Larger doses do not cause deeper 
sleep but give rise to delirium and excite- 
ment resembling those following atropin. 
In one or two cases collapse has been 
observed from the use of scopolamin. The 
vaso-motor and respiratory centres do not 
seem to be stimulated as by atropin, the 
blood-pressure falling and the respiration 
becoming slower from the beginning." 
(Cushny.) 

H. G. Barbour found in his recent ex- 
periments that morphin and scopolamin did 
not inhibit the activity of the uterus in cats. 
He believes that the delay in labor produced 
by either or both of these drugs is probably 
due entirely to their cerebral action. (The 
Journal of Pharm. and Exp. Thera., 1915, 
vii, 647.) 

Barbour and Copenhaver in their experi- 
ments with scopolamin and morphin on the 
pregnant and non-pregnant uterus of 

32 



PAINLESS CHILDBIRTH 



guinea pig and cat did not observe the 
inhibitory action upon the tone of the uterus 
described by Kehrer for large doses. They 
found that very high concentrations of 
either tend to produce a titanic condition 
of the uterus. (The Journal of Pharm. 
and Eocp. Thera., 1915, vil, 529.) 
Toxicology 

Gwathmey states that: "When nitrous 
oxid is given pure or alone, death is always 
due to oxygen deprivation and asphyxia. 
The heart continues to beat after respira- 
tion has ceased, which proves that death is 
not due to failure of circulation." 

Hewitt was able to find thirty deaths 
occurring during the administration of 
nitrous oxid, reported in the literature prior 
to 1901. At least fifteen of these were due 
to asphyxia with nitrous oxid. A few 
deaths have occurred during the adminis- 
tration of nitrous oxid and oxygen as an 
anesthetic, but always in cases which 

33 



PAINLESS CHILDBIRTH 



would undoubtedly have died under any 
anesthetic, or from asphyxia due to some 
interference with the proper flow of oxygen 
during the use of some complicated appa- 
ratus by an inexperienced anesthetist. 

Tanner warns us that: "It must not 
be forgotten that not a few individuals are 
unable to take even one-third of a grain 
(opium) without becoming narcotized. 
Young children are particularly susceptible 
to its effects; the tenth and twelfth parts 
of a grain having proved fatal to infants 
two and five days old; and there is recorded 
the case of an infant seven days old who 
died comatose eighteen hours after having 
had administered to it the twelfth of a 
grain opium or the quantity contained in a 
drop of laudanum." (Tanner, Memoranda 
on Poisons.) 

Scopolamin alone has never been the 
cause of death, but Stevens warns us that: 
"As scopolamin and morphin, however, are 

34 



PAINLESS CHILDBIRTH 



not, as was formerly supposed, antagonistic 
in their action on respiration, considerable 
caution should be exercised in using them 
conjointly in such large doses." (Materia 
Medica and Therapeutics, P. 77.) 

M. I. Smith found that the toxicity of the 
scopolamin-morphin combination in the 
mouse is increased with the relative increase 
of the scopolamin content of the combined 
dose. (The Journal of Pharm. and Eocp. 
Thera., 19 15, vn, 407.) 

The above comparative study of the 
chemicals used in the nitrous oxid-oxygen 
analgesia and in the Dammerschlaf, shows 
that while the first does not appear to inter- 
fere with the normal physiological processes 
and is free from all danger so long as a 
proper amount of oxygen is given, the 
second group of drugs even in small doses 
do interfere with normal physiological pro- 
cesses and that children are very susceptible 
to even very small doses. 

35 



PAINLESS CHILDBIRTH 



Comparative Safety of Anesthetics 

In speaking of the comparative safety 
of anesthetics, Louis Frank says: "Avail- 
able statistics show that the average mor- 
tality from chloroform is one in 3000, 
whereas, that of ether is one in about 30,000 
administrations. The action of both drugs 
is through absorption by the lipoids; both 
produce lower blood pressure, both produce 
marked depression; in other words, their 
administration is accompanied with mani- 
festations identical with those recognized 
as due to shock. . . . The comparative 
safety of nitrous oxid was demonstrated by 
the researches of Buchanan, who found 
after a careful study of statistics covering 
many millions of inhalations of this gas 
that the mortality was probably about one 
in 5,250,000 administrations." (American 
Journal of Obstetrics, N. Y., 1915, lxxi, 
630.) However, from a large experience 

36 



PAINLESS CHILDBIRTH 



with nitrous oxid, I doubt it being this safe 
if given to the stage of anesthesia by the 
average physician, and consider as more 
probable the statement of Miller, who says : 
"The statistics of nitrous oxid vary from 
one death in 100,000 to one in 750,000 
cases." (Journal of the American Medical 
Association, 1912, lix, 1847.) 

In his report on the use of scopolamin 
and morphin in surgery and obstetrics, 
Hatcher says: "H. C. Wood Jr. studied 
the cause of death in 23 cases in which 
scopolamin and morphin had been used, 
and he concluded that at least 9 of these 
deaths must be attributed to the scopolamin 
and morphin, the death rate being one to 
250 narcoses." ... In speaking of 
its use in obstetrics he says of the Dam- 
merschlaf ("Twilight Sleep") : "It is one 
of the cardinal principles of medicine to 
avoid the use of narcotics, and particularly 
morphin with infants, and it is difficult to 

37 



PAINLESS CHILDBIRTH 



believe that its use is wholly devoid of 
injurious actions." (Journal of the Ameri- 
can Medical Association, 1910, liv, 516.) 



38 



CHAPTER IV 

Nitrous Oxid and Oxygen in American 

Obstetrics 

Dr. J. Clarence Webster of Chicago was 
one of the first in America, if not the first, 
to use nitrous oxid and oxygen in obstet- 
rical practice. About ten years ago he 
began to use this anesthetic in operative 
obstetrics when the use of ether and chloro- 
form were contraindicated, and gradually 
extended its use to all types of cases. 
(Jour. A. M. A., 1915, lxiv, 812.) In 
1909 the writer gave the anesthetic for Dr. 
Webster when he performed the first 
Cesarean section operation under nitrous 
oxid and oxygen. During that year we 
gave this anesthetic for all types of oper- 
ative obstetrics, and in one primipara gave 
the gas for about two hours prior to a for- 

39 



PAINLESS CHILDBIRTH 



ceps delivery. (Jour. A. M. A., 1915 ) 
lxv, 992.) Although at that time we 
appreciated the value of nitrous oxid and 
oxygen in obstetrical practice, its use was 
limited to the end of the second stage of 
labor as the hospital was not willing to 
bear the supposedly excessive cost of its 
prolonged administration. Arthur Guedel 
of Indianapolis in 1911 advocated the use 
of nitrous oxid-air analgesia during the 
second stage of labor. (Indianapolis Med. 
Jour., Oct., 1911.) (Jour. Ind. State Med. 
Ass'n., March, 1915.) But our first knowl- 
edge of its prolonged use in America was in 
July, 1913, when Drs. Lynch and Hoag 
confined the daughter of a Mr. Clark, the 
maker of a gas machine. Dr. Lynch says 
that Mr. Clark "sought at his own risk to 
try in his family the method which his 
demonstrators were teaching for dentistry." 
The analgesia was maintained for over five 
hours. Dr. Lynch was very enthusiastic 

40 



PAINLESS CHILDBIRTH 



over the results obtained and since then has 
been a constant user of the analgesia. The 
other members of our obstetrical staff, Drs. 
N. S. Heaney and Carey Culbertson, are 
equally enthusiastic. 

During the past two years nitrous oxid- 
oxygen analgesia has been used by Chicago 
obstetricians in several hundred cases. In 
nearly every case a few deep inhalations 
of the gas has relieved the severity of the 
contraction. In no case has the labor been 
delayed, but rather it has been hastened 
because of better assistance on the part of 
the mother. The duration of labor is appar- 
ently shortened about 25 per cent, by the 
nitrous oxid analgesia. It gives an increased 
control over the patient and there are none 
of the hysterical outbursts formerly occur- 
ring in the delivery room. No longer are 
the patients in the other parts of the hos- 
pital disturbed by the outcries of the expect- 
ant mothers. The babies cry as quickly 

41 



PAINLESS CHILDBIRTH 



after the use of the analgesia as when no 
anesthetic is given. 

The actual cost of the nitrous oxid and 
oxygen for the ordinary obstetrical case is 
small, the prevention of suffering and shock 
is invaluable. The longest over which I have 
had to administer the analgesia was nearly 
eleven hours, in a primipara with a con- 
tracted pelvis of moderate degree and a dry 
labor. The cost of the gas used in this case 
was six dollars. With multipara it is rarely 
necessary to administer the analgesia longer 
than two hours. In primipara the labor 
is usually terminated within three hours 
from the beginning of the painful con- 
tractions. 

In maintaining analgesia the confidence 
and cooperation of the patient is necessary. 
The more intelligent the patient, the easier 
it is to obtain satisfactory results. 



42 



CHAPTER V 

Objections to "Twilight Sleep" 

The so-called "Twilight Sleep" or Ddm- 
merschlaf has been used in several thousand 
cases, and in the hands of the most skilled 
the results have been fairly satisfactory in 
from 80 to 90 per cent of the cases. 
However, the use of the scopolamin and 
morphin narcosis in surgery is known to 
be far more dangerous for the average 
case than any other anesthetic. The sus- 
ceptibility of infants and certain adults to 
opium or its alkaloids cannot be questioned. 
We know that the infant in utero may 
absorb enough of the narcotic to render 
resuscitation difficult and that at times the 
infant has died. 

Those who have had the largest expe- 
rience with scopolamin and morphin or nar- 

43 



PAINLESS CHILDBIRTH 



cophin in obstetrical practice are agreed 
that this method should be used only by the 
obstetrical specialist; it should be used only 
in a specially equipped delivery room which 
is protected from all noise and confusion; 
the physician must be in constant attend- 
ance; a large experience in the use of the 
drugs is necessary; the action of the scopo- 
lamin and morphin is uncertain ; the patients 
are at times very hard to control; and fail- 
ures are to be expected in 10 per cent or 
more of the cases subjected to the 
treatment. 

Dr. Webster says: "In spite of the pub- 
licity which has been given this so-called 
'Twilight Sleep' method by the lay press 
it has not found favor with the majority 
of the leading obstetric authorities in 
Europe or America. They are too well 
aware of the uncertain effects produced by 
the mixture and of the complications which 
may be caused, to adopt it. For many 

44 



PAINLESS CHILDBIRTH 



generations obstetricians have avoided the 
use of morphin, except in rare cases, 
because of its bad effect on the child and 
its interference with the muscular activity 
in the mother. Scopolamin is variable and 
uncertain in its action and very often pro- 
duces marked excitement in the woman, 
which may greatly interfere with the carry- 
ing out of a clean technic. The lay press 
has not referred to the mental disturbances 
which have been produced nor have they 
made know that in that part of Germany 
where the procedure originated, a large 
number of damage suits have been instituted 
in the courts against prominent physicians, 
because of various ill effects alleged to be 
due to 'Twilight Sleep.' " {Jour. A. M. 
A., 1915, lxiv, 812.) 

In discussing "Twilight Sleep," or the 
semi-narcosis of scopolamin and morphin, 
Dr. F. W. Lynch has well said: 

"From the standpoint of pure theory, the 

45 



PAINLESS CHILDBIRTH 



method presents many faults. The pro- 
cedure is theoretically perfect for the first 
stage, yet the first stage is usually neither 
dangerous or difficult to withstand. Heart 
cases, pneumonias, typhoids and toxemias 
pass safely through it, to meet trouble in 
the second stage. Were relief from pain 
possible in but one of these two stages, 
there is no doubt but that the second would 
be selected for such protection. Yet the 
failures of the seminarcosis occur during 
this period. The second stage is prolonged 
and distorted from the normal picture. It 
commonly requires augmentation or artifi- 
cial delivery. There is considerable danger 
to the child at this time. Proper asepsis 
is often impossible. Nor is the method ideal 
in its action. There is the objection com- 
mon to all medicines, that a drug once 
given by the hypodermic is beyond recall, 
although this is controlled to some degree 
by the rapid excretion. Yet the drug 

46 



PAINLESS CHILDBIRTH 



utterly fails to protect the brain. Sensory 
perceptions are not markedly inhibited in 
the proper doses of the method. The 
patient complains of pain and reacts to it 
as much as the motor incoordination will 
permit. Sensory perceptions are dimin- 
ished by shading the lights, stopping the 
ears with cotton, and giving smoked glasses 
for the eyes, and restricting sounds and 
noises as much as possible. Yet stimulation 
of pain reaches the brain. The drugs cause 
motor incoordination rather than a checking 
of sensory impressions. To all intents and 
purposes the patient is drunk. Thus the 
alcoholic receives sensory impressions, but 
presents motor incoordination. He argues, 
and complains, and wakes the following 
morning with utter forgetfulness of the 
events of the recent past. He, too, has 
amnesia. Cases have been reported which 
have been delivered painlessly during alco- 
holic drunkenness, or else remembered no 

47 



PAINLESS CHILDBIRTH 



pain. Rush, years ago, cited the case 
recorded by Church, Allright that of 
Daneux, etc." (III. Med. Jour., 1915, 
xxyii, 257.) 



48 



CHAPTER VI 

Advantages of Nitrous Oxid-Oxygen 
Analgesia 

Nitrous oxid and oxygen is conceded to 
be the safest of anesthetics. Nitrous oxid 
can only cause death from asphyxia, and 
in giving the analgesia this is impossible 
owing to the use of oxygen and the few 
inhalations required. It is quickly elimi- 
nated and has no bad effects on the mother 
or child. In no case will the analgesia 
lengthen labor, but rather will shorten it 
because of better assistance on the part of 
the mother. It is easier to carry a hypo- 
dermic needle than a gas machine ; but while 
the "Freiburg Method" should be used only 
by the specialist, the nitrous oocid-oxygen 
analgesia may he used safely and efficiently 

49 



PAINLESS CHILDBIRTH 



by every physician who is trained in the 
science of obstetrics. It can be adminis- 
tered as safely in the home as in the 
hospital. (It is not admitted that an 
obstetrical case is as safe in the home as 
in the maternity hospital.) It may be used 
in all classes of cases, the results varying 
with the cooperation of the patient and the 
skill of the obstetrician. It gives an in- 
creased control over the patient in that 
there are none of the hysterical outbursts 
formerly occurring in the delivery room. 
Neither Ddmmerschlaf nor nitrous oocid- 
oocygen analgesia can take the place of 
clean, scientific obstetrics, but with the 
demand of women for the relief of labor 
pains, will come an increased intelligence 
regarding childbirth, and better obstetrics 
must result. 

In an alternating series of cases at a 
Brooklyn Hospital, Allen observed that the 

50 



PAINLESS CHILDBIRTH 



women under the scopolamin and morphin 
were in labor longer and did not feel as 
well afterwards as the women who had the 
nitrous oxid-oxygen analgesia. (N. A. 
Jour, of Horn., 1914, xxix, Nov.) 

It may be better to give the "Twilight 
Sleep" than to let the woman suffer in- 
tensely, but drugs act differently; people 
have their idiosyncrasies; the hypodermic 
injection of the scopolamin and morphin 
is beyond recall. We concede that the 
suffering of labor may be relieved with 
the prolonged administration of ether or 
chloroform, but the reports from large 
clinics and from laboratory investigators 
show that these anesthetics are not free 
from danger and that they must be used 
with great care. On the other hand, in the 
use of the nitrous oxid-oxygen analgesia we 
have eutocia without danger to mother or 
child. The nitrous oxid-oxygen analgesia, 

51 



PAINLESS CHILDBIRTH 



being safe and certain, is the logical method 
of relieving the pangs of childbirth. It is 
a method which does not interfere with an 
aseptic technic. 



52 



PART II 
EUTOCIA 



Suffering during labor is but the tide 
in the ocean of motherhood, and the desire 
of mothers is eutocia — not amnesia. 



CHAPTER VII 

EUTOCIA 

It is the right of woman to demand relief 
from the pains of childbirth, and it is the 
duty of the physician to relieve her of these 
pains in the same spirit that he relieves 
other suffering. The pain of labor causes 
shock and is, I believe, more dangerous than 
the proper use of any of the analgesics now 
employed. Yet it is the duty and should 
be the aim of every physician to employ 
the safest and best measures in the care of 
his patients. 

Physicians complain that they cannot 
give their patients better obstetrical care 
because of the ridiculously low fees, and 
it is a fact that people do pay several times 
as much for an appendectomy as for a con- 

55 



EUTOCIA 



finement. The American public, including 
many physicians, must learn that training, 
cleanliness and adequate facilities are as 
necessary for the confinement as for the 
surgical operation. For the physician with 
a surgical training, the appendectomy, when 
difficult, is still a more simple procedure 
than the difficult obstetrical operation; it 
requires no greater skill and less experience. 
In the obstetrical procedure two lives are 
often in the balance. 

Major surgery has become relatively safe 
because of the surgical specialist and the 
adequate facilities of the modern hospital. 
The internal medicine specialist and the 
general practitioner take their patients to 
the hospital for medical treatment because 
experience shows that hospital treatment 
insures a better prognosis. 

We honor the mother above all other 
women. We set aside one Sunday each 
year to voice her praises. If she develops 

56 



EUTOCIA 



tuberculosis, she is sent to a sanitorium for 
treatment. If she has a tumor, she is sent 
to the hospital for an operation. If she has 
arthritis, pneumonia, typhoid fever, or 
gastric ulcer, she is sent to the hospital 
because it betters her chances for life and 
health. But for the crowning event of her 
life — motherhood — there is no adequate 
provision. Our hospitals have a few beds 
for operative cases, but the great mass of 
women must of necessity be delivered at 
home. More than half of the women in 
our large cities are still confined by ignorant 
and, too often, filthy midwives. 

It is a disgrace to the American people 
that during the past half century there has 
been no decrease in obstetrical mortality and 
morbidity outside of the hospitals. It is a 
disgrace to the medical profession that, 
after carefully investigating the midwife 
problem for the American Medical Asso- 
ciation, Professor J. W. Williams was 

57 



EUTOCIA 



forced to say: "Ordinary practitioners lose 
proportionately as many women from puer- 
peral infections as do midwives." And 
"more deaths occur each year from opera- 
tions improperly performed by practitioners 
than from infection in the hands of mid- 
wives." Williams urges: "Education of 
the laity that poorly trained doctors are 
dangerous, that most of the ills of women 
result from poor obstetrics, and that poor 
women in fairly well conducted free 
hospitals usually receive better care than 
well-to-do women in their own homes; that 
the remedy lies in their own hands and that 
competent obstetricians will be forthcoming 
as soon as they are demanded." {Jour. 
A. M. A., 1912, lviii, 1.) 

It is a disgrace to the hospital boards 
that, while they are providing so many 
beautiful hospitals with thousands of beds 
for the medical and surgical treatment of 
men, women and children, they have only 

58 



EUTOCIA 



a few beds for maternity cases. It reflects 
on their financial judgment to give so many- 
free beds for the medical and surgical 
treatment of conditions which proper 
obstetrical care would have prevented. 

How much longer are the mothers who 
suffer from unnecessary ills going to suffer 
in silence? Are the husbands who bear the 
burdens of the unnecessary invalidism going 
to do so forever and make no effort to 
secure safer obstetrics? Are the mothers 
who are more or less invalided because of 
poor obstetrics and lack of proper facilities 
going to allow their daughters to grow into 
motherhood and, with open eyes, endure 
the same unnecessary suffering? 

Women writers, woman's clubs, and the 
"Twilight Sleep" Association are urging the 
German Dammerschlaf as a means of secur- 
ing painless childbirth. Important as pain- 
less childbirth may be, it is only one wave 
in the sea of obstetrical problems. The time 

59 



EUTOCIA 



has come when women must take a few 
hours from the church, the club and politics 
to protect motherhood by demanding that 
maternity be given its proper place in 
modern preventive medicine. Let them 
learn that obstetrical accidents will some- 
times happen in the hands of the most 
skilled, but that the large percentage of the 
bad results are due to ignorance and lack 
of surgical cleanliness; that most of the ills 
following childbirth are due to poor ob- 
stetrics and are unnecessary, and they will 
then demand the same skilled care in child- 
bed that they demand when they undergo 
a surgical operation. 

The chief dangers of maternity can be 
eliminated by proper pre-natal care and 
confinements conducted in a clean and 
scientific manner in properly equipped hos- 
pitals. In relieving the pain of labor 
competent physicians must use the method 
safest for both mother and child. Suffering 

60 



EUTOCIA 



during labor is but the tide in the ocean 
of motherhood and the desire of mothers 
is eutocia, — not amnesia. 



61 



CHAPTER VIII 

Obstetrical Facts and Comparative 
Statistics 

In the preceding pages several state- 
ments were made which will to the average 
mind seem farfetched. To believe that the 
obstetrical mortality of today is as great as 
it was before the discovery of anesthesia and 
antiseptics, is difficult unless one is con- 
fronted with facts. It is probable that 
very few physicians realize that with the 
great progress of preventive medicine and 
aseptic surgery that there has not been a 
similar increase in the safety of maternity. 
The responsibility for the present high 
mortality cannot be laid at the door of the 
midwife, for physicians confine a far greater 
percentage of the women today than a half 
century ago. 

62 



EUTOCIA 



By means of liberal quotations from the 
writings of obstetrical authorities, together 
with mortality statistics of the several coun- 
tries the author has hoped to arouse the 
reader to realize the great need of better, 
safer obstetrics. 

The mortality records of the United 
States show that there are only two and 
one-half times as many women of child- 
bearing ages who die from tuberculosis as 
die each year from puerperal sepsis and 
other obstetrical complications, and when 
we consider that not more than one woman 
in fifteen of the female population between 
15 and 45 is delivered of a full-term child 
during the year the awfulness of existing 
conditions becomes more apparent. 

De Lee says of puerperal sepsis: "It 
kills one in four hundred women delivered 
of full term children; it leaves as incurable 
invalids at least ten times this number. 
(De Lee: "Obstetrics" p. 872.) 

63 



3> 



EUTOCIA 



That puerperal sepsis may be largely 
eliminated is shown by the records of the 
large maternity hospitals and by the experi- 
ence of trained obstetricians. Obstetrical 
operations should be relatively safe, but 
the haphazard use of the obstetrical forceps 
and other operative procedures has appar- 
ently prevented a lowering of the operative 
mortality. 

While 5,131 babies died from injuries at 
birth, 27,359 from premature birth, and 
20,375 from congenital debility (?) in 
the registration area during 1913, this vast 
loss will not be discussed since better ob- 
stetrics means a great lowering of the 
infant mortality. The registration area 
comprised 65.1 per cent of our population, 
or 63,298,718 people. . 

Our laws may be responsible to some 
degree for present conditions, but as Judge 
Lindsay has said: "Law is beneficial to 
society just in proportion to the degree 

64 



EUTOCIA 



it is sustained and influenced by public 
opinion and influenced through the pressure 
of public opinion." 

Haultain, discussing this subject, quotes 
from the writings of £hampneys, who 
says : 

"Up till 1900 there was an increasing 
number of deaths from sepsis, since then 
it has decidedly dropped. To the adoption 
of the Midwives Act this may fairly be said 
to be due, the majority of mothers being 
now attended by women educated in the 
principles of cleanliness and antisepsis. 

"In 1902, when this act came into force, 
the death rate from puerperal sepsis per 
million women was 118. 

"In 1907 it fell to 81. As the 1901 
census shows the number of women in Eng- 
land and Wales to be 16,800,000, the fall of 
37 per million means that, without estimat- 
ing actual increase in the number of women, 
621 women were saved from this disease 

65 



EUTOCIA 



alone who would have died in 1902." 
(Haultain, Trans. Edin. Obs. Soc. 1910-11, 
xxxvi, 15.) 

Addressing the Edinburg Obstetrical 
Society in November, 1900, R. Milne 
Murray said: 

"We stand today 'the heirs of the ages/ 
and in virtue of the labors of those who 
have gone before us, we claim that for 
every strictly obstetrical complication which 
can arise, with only perhaps one exception, 
we have at our disposal a procedure with 
which we can meet it; that, in fact, there is 
scarcely a peril which can beset a woman in 
travail, out of which we have not the means 
of rescuing her. Of course I speak of 
strictly obstetrical complications. There 
are accidental diseases, such as grave dis- 
orders of the nutritive apparatus, of the 
heart, lungs, kidneys, etc., which produce 
conditions with which obstetric medicine is 
at present powerless to deal. 

66 



EUTOCIA 



"But for all else (save perhaps eclampsia) 
we profess a remedy, provided always we 
are entrusted with the care of the patient 
in reasonable time. Malpresentation, mal- 
position, deformed pelvis, of whatever de- 
gree, hemorrhage of whatever sort, rupture 
of the uterus, each and all have their appro- 
priate treatment which has been tested 
times and times again, and has stood the 
test with unqualified success. This, then, 
is the profession, and the reasonable pro- 
fession made by the obstetrician today, 
armed as he should be with an accurate 
knowledge of obstetrics, and with anesthetics 
and the technic of antiseptic surgery. 

"Surely, then, the trees of the Arician 
Grove are dead and withered, for no woman 
now need come to the shrine of the goddess ; 
and surely also the Litany for 'all women 
laboring of child' is obsolete and forgotten. 
Alas! it is not so, for the trees of the grove 
are green as ever, and the altar of the 

67 



EUTOCIA 



goddess is laden with offerings, and the 
Litany goes up each day from trembling 
lips and sinking hearts; for each year, in 
our land alone, nearly 5,000 women fall 
and perish in the perils of childbed. 

"Where now is our proud boast? What 
are we to say for modern midwifery when 
we witness year by year this sacrifice of fifty 
hecatombs of the most precious lives in the 
whole community, most of them in the very 
prime of life, many of them already the 
mothers of helpless children? Are we to 
fall back on the council of despair and 
declare this to be the irreducible minimum? 
Surely by all that is reasonable, NO! 

"Let us look at the facts a little more 
closely. Between the years 1847 and 1856, 
the average annual death rate from puer- 
peral fever was 1.89 per 1,000. During 
these years chloroform was coming into use, 
but was by no means generally employed, 

68 



EUTOCIA 



and antiseptics had scarcely been thought 
of. 

"Between the years 1875 and 1884 the 
mortality from the same cause rose to 2.28 
per 1,000. By this time anesthetics were 
in wide use and antiseptic methods had been 
taught and practiced to a very great extent. 

"Between the years 1886 and 1895 the 
mortality had now risen to 2.46 per 1,000. 
During this time anesthetics and antisepsis 
may be supposed to have been almost uni- 
versally practiced." 

But contrasted with these statistics 
regarding the general mortality from puer- 
peral sepsis are those from the maternity 
hospitals which before the use of antiseptics 
were veritable morgues. In speaking of 
this change J. Halliday Croom {Trans. 
Edinburg Obstetrical Society, vol. xiii) 
says: 

"Everyone knows that at one time a 

69 



EUTOCIA 



mortality of 15 to 20 per cent was by no 
means uncommon. Will anyone dare to 
say that antiseptics have not entirely and 
absolutely revolutionized this? How else 
can we explain the recent history of such 
hospitals as those in Paris, Prague, Copen- 
hagen, London, and Edinburg, where, as 
a matter of fact, the disease has been prac- 
tically stamped out. I doubt if there is a 
more striking practical fact in the whole 
history of medicine than that in the hospitals 
I have just mentioned, when, without any 
external or internal change in the hospitals 
except the introduction of antiseptics, the 
mortality should have fallen from 20 per 
cent to almost nil" 

De Lee, in his "Obstetrics" (p. 871), 
says that "in Germany about 5,000 women 
are lost each year from infection, and fully 
as many more from accidents of childbirth." 
He quotes from Von Herff, who recently 
called attention to a slight but persistent — 

70 



EUTOCIA 



and deplorable rising of the mortality from 
sepsis, which he ascribes to the lack of 
aseptic practice by the physicians and the 
increase of obstetric operating. 

"Von Herff, in 1906, reported in Basil, 
up to that date, 6,000 cases had been 
delivered without a single death (from 
sepsis). Lea quotes Ahlfeld, Marburg, as 
having had 8,000 cases with one death, the 
infection having been acquired in the hos- 
pital, but the patient had examined herself. 
In the Rotunda Maternity, Dublin, 2,060 
women were delivered without mortality 
from infection caused in the hospital, and 
Dr. Broxall gives the record of York Road 
Lying-in Hospital, with 8,373 deliveries 
without death from infection, ascribable to 
the hospital care." (De Lee.) 



71 



CHAPTER IX 

Unnecessary Mortality 

We are all familiar with the ravages of 
tuberculosis and cancer. During the past 
few years there has been a splendid effort 
to control the white plague. The results 
show that the effort was not in vain. Can- 
cer has now come to be the dread disease of 
the country and much time and money is 
being spent in the effort to discover its 
cause and to educate the people to the need 
of an early diagnosis and operation. But 
the mortality records in the United States 
indicate that there has been no lessening in 
the dangers of maternity during the time 
vital statistics have been recorded. 

A study of the mortality statistics from 
the area of registration in the United 
States for the year 1913, shows that 26,265 

72 



EUTOCIA 



women between 15 and 45 years of age died 
of tuberculosis, and 5,065 from cancer. 
During the same period 4,542 died from 
puerperal sepsis and 5,468 from other 
obstetrical accidents. 

It is unfortunate that in computing the 
mortality statistics for puerperal sepsis 
that the government reports give the deaths 
per 100,000 for the entire population when 
only a few of the total population bear 
children. Because of this fact the enor- 
mous maternal mortality has not been 
apparent when compared with the statis- 
tics for tuberculosis and cancer. Yet it is 
seen that nearly as many women of child- 
bearing age die yearly from puerperal 
sepsis as do from cancer, and maternity is 
responsible for twice as many deaths each 
year as is cancer. It is also evident that 
for every six deaths from tuberculosis 
among women between 15 and 45, that one 
dies from puerperal sepsis. While there 

73 



EUTOCIA 



are two and one-half times as many women 
of the childbearing age die from tuber- 
culosis as do from sepsis and other obstet- 
rical complications, it must be remembered 
that only 53.4 per cent of the women 
between 15 and 45 are married and that of 
the married women not more than one in 
eight will have children any one year. 
Without giving figures it is evident that 
maternity is a greater danger to our women 
than is tuberculosis. 

If puerperal infection kills 1 in 400 
women delivered of full-term children, it 
kills 250 in every 100,000 deliveries. The 
mortality statistics in the registration area 
of the United States for 1913, shows that 
per 100,000 population that 78.9 died of 
cancer; 127.7 from pulmonary tuberculosis; 
8.7 from scarlet fever; 18.8 from diphtheria 
and croup; 12.8 from measles; and 17.9 
from typhoid fever. These statistics give 
puerperal sepsis as 7.2 and other puerperal 

74 



EUTOCIA 



accidents as 8.6 per 100,000 population. 
These statistics indicate that there is twice 
as much danger of the pregnant woman 
dying from puerperal sepsis as there is of 
the average woman developing tuberculosis. 
On the other hand statistics show that puer- 
peral sepsis has in well regulated maternity 
hospitals been reduced to almost nil. 

With all the advancement in the science 
of obstetrics, in this age of low surgical 
mortality and preventive medicine, why 
is maternity so dangerous? Why has there 
been a slight increase in the number of 
deaths from puerperal sepsis and other 
obstetrical complications since the discovery 
of anesthetics and antisepsis? Milne Mur- 
ray answered this when he said: 

"I feel sure that an explanation of much 
of the increase of maternal mortality from 
1847 onward will be found in, first, the 
misuse of anesthesia, and second, in the 
ridiculous parody which, in many practi- 

75 



EUTOCIA 



th 



tioners* hands, stands for the use of anti- 
septics. In a word, the use which has been 
made by many of two of the greatest 
blessings of humanity has converted them 
into little else than a curse. Before the 
days of anesthesia interference was limited 
and obstetric operations were at a minimum, 
because interference of all kinds increased 
e conscious suffering of the patient. Thus 
forceps and turning were employed when 
natural efforts had failed, and such opera- 
tions as the artificial dilatation of a rigid os 
were not attempted until it became an 
urgent necessity. When anesthesia became 
possible and interference became more fre- 
quent, because it involved no additional 
suffering, operations were undertaken when 
really unnecessary on the demand of the 
patient or for the convenience of the prac- 
titioner. And so complications arose and 
the dangers of labor increased. But the 

76 



EUTOCIA 



knowledge that this interference involved 
risks must have served as a salutary check 
to some extent. I doubt not that a split 
cervix, followed by a fatal hemorrhage or a 
death from puerperal sepsis must have 
burned its lesson into more than one reflec- 
tive conscience in these days. 

"Then came the antiseptic era. Here 
was now the panacea for all the dangers 
of childbed. All that was necessary was 
to dip the instruments for a few minutes 
in a carbolic lotion, and the hands in one 
of half the strength for half the time, and 
all the danger was at an end. The forceps 
were passed through an undilated os; if it 
tore slightly, no matter, the antiseptic made 
that quite safe. Turning was now a matter 
of mere manipulative skill — a clean hand 
in the uterus could do no harm. This is 
no mere caricature: and if it represents 
the methods of any reasonable proportion 

77 



EUTOCIA 



of practitioners what wonder the cup was 
so often filled with death? When we hear 
of men who admit that forceps cases repre- 
sent 30 to 70 per cent of their practice, we 
wonder what the antiseptic precautions are 
which they claim as their justification. 
Normal labor is a natural process which is 
best left to itself, and the less the patient 
is disturbed with the paraphernalia of 
obstetrics before or after, the better. 
Until men realize this and 
recognize the fact that the simplest obstetric 
operation demands not one whit less of 
care as to antiseptic precautions than is 
required of one before opening the abdomen, 
we shall get no further forward. . 

"When the practical obstetrician realizes 
his responsibility, and that no small share 
of this terrible maternal mortality of a 
certainty lies at his door, he has made the 
first step towards true progress. When he 

78 



EUTOCIA 



realizes that labor is a natural process which 
in the great majority of cases it is criminal 
to disturb; when he realizes that every inter- 
ference increases the inherent dangers a 
hundred-fold; and when under this con- 
sciousness he brings with him to the lying-in 
room all that is possible of those principles 
of antiseptic surgery which have been at 
the bottom of the triumphs of modern 
gynecology, we shall not have long to wait 
for the lightening of the dark cloud which 
hangs over us now." 

More and better maternities, with ob- 
stetrics practiced only by clean physicians, 
with surgical care, and on a scientific basis, 
is the great obstetrical need of today. 
Eutocia should be the desire of every 
woman and the aim of every physician. 

The following tables are submitted as 
further proof of the statements made in the 
preceding pages. 

79 



EUTOCIA 



Table 1 
puerperal, deaths, 1855-1909 







SCOTLAND 














Deaths per 1000 










Confinements 






Deaths from 


from 




Estimated 




Other 




Other 




Number 




Puer- 


Puer- 


Puer- 




of Con- 


Puerperal 


peral 


peral 


peral 


Ifear 


finements 


Fever 


Causes 


Fever 


Causes 


1855 


96,850 


169 


341 


1.7 


3.6 


1856 


105,556 


143 


351 


1.4 


3.3 


1857 


107,186 


145 


304 


1.4 


2.8 


1858 


107,858 


152 


302 


1.4 


2.8 


1859 


110,445 


175 


333 


1.6 


3.0 


1860 


109,553 


236 


328 


2.2 


2.9 


1861 


111,010 


203 


308 


1.8 


2.8 


1862 


111,042 


130 


305 


1.2 


2.7 


1863 


113,465 


195 


376 


1.7 


3.3 


1864 


116,526 


254 


374 


2.2 


3.2 


1865 


117,272 


213 


422 


1.8 


3.6 


1866 


117,891 


181 


356 


1.5 


3.1 


1867 


118,285 


163 


321 


1.4 


2.7 


1868 


119,743 


140 


354 


1.2 


2.9 


1869 


117,513 


153 


410 


1.3 


3.5 


1870 


119,687 


202 


381 


1.7 


3.2 


1871 


120,535 


225 


420 


1.9 


3.5 


1872 


123,228 


219 


391 


1.8 


3.2 


1873 


124,173 


251 


325 


2.0 


2.6 


1874 


128,282 


378 


442 


2.9 


3.5 


1875 


128,187 


389 


459 


3.0 


3.6 


1876 


131,283 


231 


374 


1.8 


2.8 


1877 


131,637 


163 


394 


1.2 


3.0 


1878 


131,651 


164 


380 


1.2 


2.9 


1879 


130,450 


184 


397 


1.4 


3.1 


1880 


129,272 


185 


416 


1.4 


3.2 


1881 


130,963 


235 


462 


1.8 


3.5 


1882 


130,965 


267 


403 


2.0 


3.1 


1883 


129,205 


363 


427 


2.8 


3.3 


1884 


134,045 


336 


371 


2.5 


2.8 


1885 


130,881 


374 


405 


2.9 


3.1 


1886 


132,866 


270 


331 


2.0 


2.5 


1887 


129,199 


275 


338 


2.1 


2.6 


1888 


127,958 


309 


351 


2.4 


2.8 


1889 


127,407 


277 


346 


2.2 


2.7 


1890 


126,083 


324 


363 


2.6 


2.8 


1891 


130,815 


378 


. 340 


2.9 


2.6 


1892 


129,718 


315 


373 


2.4 


2.9 


1893 


131,902 


252 


336 


1.9 


2.6 


1894 


129,036 


285 


342 


2.2 


2.7 


1895 


131,384 


253 


355 


1.9 


2.7 


1896 


134,019 


220 


357 


1.6 


2.7 



80 



EUTOCIA 



Table 1 — continued 













Deaths per 1000 












Confinements 






Deaths from 


from 




Estimated 






Other 




Other 




Number 






Puer- 


Puer- 


Puer- 




of Con- 


Puerperal 


peral 


peral 


peral 


Year 


finements 


Fever 


Causes 


Fever 


Causes 


1897 


133,846 


205 




331 


1.5 


2.5 


1898 


135,852 


227 




351 


1.7 


2.6 


1899 


135,702 


214 




341 


1.6 


2.5 


1900 


136,318 


225 
S. P. 


F.* 


342 


1.7 


2.5 


1901 


137,150 


118 4 


158 


347 


2.0 


2.6 


1902 


137,127 


106 3 


198 


375 


2.2 


2.8 


1903 


138,489 


110 6 


175 


418 


2.1 


3.0 


1904 


137,512 


113 2 


126 


374 


1.8 


2.7 


1905 


136,245 


124 5 


119 


450 


1.8 


3.5 


1906 


136,961 


123 10 


130 


442 


1.9 


3.3 


1907 


133,492 


135 6 


87 


451 


1.7 


3.4 


1908 


136,140 


107 3 


121 


435 


1.7 


3.3 


1909 




... . 











•S. — Septicaemia and Saprsemia. P. — Pyaemia. F — .Fever. 



Table 2 







ENGLAND 


AND WALES 














Deaths per 1000 












Confinements 








Deaths from 


from 










Other 




Other 










Puer- 




Puer- 




Births 


Estimated 


Puer- 


peral 


Puer- 


peral 




Regis- 


Confine- 


peral 


Dis- 


peral 


Dis- 


Year 


tered 


ments 


Fever 


eases 


Fever 


eases 


1855 


635,043 


658,860 


1,079 


1,900 


1.6 


2.9 


1860 


684,048 


709,703 


987 


2,186 


1.4 


3.1 


1865 


748,069 


776,125 


1,333 


2,490 


1.7 


3.2 


1870 


792,787 


822,520 


1,492 


2,383 


1.8 


2.9 


1875 


850,607 


882,509 


2,504 


2,560 


2.8 


2.9 


1880 


881,643 


914,708 


1,659 


1,833 


1.8 


2.0 


1885 


894,270 


927,809 


2,420 


2,029 


2.6 


2.2 


1890 


869,937 


902,563 


2,016 


2,239 


2.2 


2.5 


1895 


922,291 


956,881 


1,927 


2,292 


2.0 


2.4 


1900 


927,062 


961,831 


2,017 


2,438 


2.1 


2.5 


1905 


929,293 


964,146 


1,734 


2,171 


1.8 


2.3 


1908 


940,383 


975,652 


1,395 


1,966 


1.4 


2.0 






IRELAND 








1865 


144,970 


150,407 


284 


644 


1.9 


4.3 


1870 


149,846 


155,466 


360 

81 


670 


2.3 


4.3 



EUTOCIA 



Table 2 — continued 



Deaths per 1000 

Confinements 









Deaths from 


from 










Other 




Other 










Puer- 




Puer- 




Births 


Estimated 


Puer- 


peral 


Puer- 


peral 




Regis- 


Confine- 


peral 


Dis- 


peral 


Dis- 


Year 


tered 


ments 


Fever 


eases 


Fever 


eases 


1875 


138,320 


143,508 


442 


563 


3.1 


3.9 


1880 


128,086 


132,890 


347 


544 


2.6 


4.1 


1885 


115,951 


120,300 


370 


495 


3.1 


4.1 


1890 


105,254 


109,201 


252 


440 


2.3 


4.0 


1895 


106,113 


110,093 


321 


448 


2.9 


4.1 


1900 


101,495 


105,264 


236 


414 


2.2 


3.9 


1905 


102,832 


106,689 


227 


346 


2.1 


3.2 


1908 


102,039 


105,866 


189 


341 


1.8 


3.2 






FINLAND 








1870 


63,748 


66,139 




535 




8.1 


1875 


69,521 


72,128 




629 


. . 


8.7 


1880 


74,784 


77,589 




654 


. . 


8.4 


1885 


75,129 


77,947 




536 


. . 


6.9 


1890 


77,860 


80,780 




460 


. . 


5.7 


1895 


81,783 


84,850 




454 


. . 


5.4 


1900 


86,339 


89,577 




427 


. . 


4.8 


1905 


87,841 


91,135 




374 




4.1 






NORWAY 








1870 


50,434 


52,325 


144 


• • 


2.8 


• • 


1875 


56,358 


58,472 


183 


... 


3.1 


• • 


1880 


58,923 


61,133 


147 


... 


2.4 


. . 


1885 


61,052 


63,342 


165 


... 


2.6 


. . 


1890 


60,108 


62,362 


159 


• . . 


2.5 


. . 


1895 


62,932 


65,292 


94 


... 


1.4 


. . 


1900 


66,149 


68,630 


111 


73 


1.6 


1.1 


1905 


















SWEDEN 








1865 


134,281 


139,317 


299 


... 


2.1 




1870 


119,838 


124,332 


380 


... 


3.1 


. . 


1875 


135,958 


141,057 


457 


... 


3.2 


. . 


1880 


134,262 


139,297 


338 


... 


2.4 


. . 


1885 


137,308 


142,458 


314 


... 


2.2 


. . 


1890 


133,597 


138,607 


173 


... 


1.2 


. , 


1895 


134,599 


139,647 


187 


... 


1.3 


. . 


1900 


138,139 


143,320 


121 


. . . 


0.8 


. . 


1905 


















SWITZERLAND 








1880 


84,165 


87,322 


361 


382 


4.1 


4.4 


1885 


80,349 


83,362 


436 


309 


5.2 


3.7 


1890 


78,548 


81,494 


253 


261 


3.1 


3.2 


1895 


84,973 


88,160 


217 


281 


2.5 


3.2 


1900 


34,316 


98,853 


193 


330 


2.0 


3.4 


1905 


94,653 


98,203 


253 


• • • 


2.6 





82 



EUTOCIA 



Table 2 — continued 











Deaths per 100O 












Confinements 








Deaths from 


from 










Other 




Other 










Puer- 




Puer- 




Births 


Estimated 


Puer- 


peral 


Puer- 


peral 




Regis- 


Confine- 


peral 


Dis- 


peral 


Dis- 


Year 


tered 


ments 


Fever 


eases 


Fever 


eases 


1875 


138,469 


143,662 


235 


651 


1.6 


4.5 


1880 


143,855 


149,250 


166 


360 


1.1 


2.4 


1885 


148,028 


153,580 


214 


463 


1.4 


3.0 


1890 


149,329 


154,929 


189 


351 


1.2 


2.3 


1895 


158,130 


164,061 


154 


328 


0.9 


2.0 


1900 


162,611 


168,710 


144 


314 


0.9 


1.9 


1905 


170,767 


177,172 


119 


295 


0.7 


1.7 






ITALY 








1887 


1,152,906 


1,196,145 


2,504 


4,436 


2.1 


3.7 


1890 


1,083,103 


1,123,724 


1,682 


2,713 


1.5 


2.4 


1895 


1,092,102 


1,133,061 


1,514 


1,893 


1.3 


1.7 


1900 


1,067,376 


1,107,407 


1,033 


2,001 


0.9 


1.8 


1905 


1,084,518 


1,125,192 


977 


2,221 


0.9 


2.0 



From "The Transactions of the Edinburgh Obstetrical 
Society/' 1910-11, XXXVI, 26. 



83 



PART III 

NITROUS OXID-OXYGEN 
ANALGESIA IN OBSTETRICS 

Technic and Conclusions 



Eutocia must be the aim. Nitrous oxid- 
oxygen analgesia should be a blessing to 
mothers, but it may, however, be converted 
into little else than a curse, unless people 
are educated to the need of better obstetrics 
and the average methods employed in 
obstetrical practice are improved. 



CHAPTER X 

Nitrous Oxid-Oxygen Analgesia in 
Obstetrics 

a comparative study or 104 consecutive 

CASES 

The administration of the nitrous oxid- 
oxygen analgesia in obstetrical practice, or 
in fact that of any form of analgesia, is 
not only time consuming and tiresome but 
it must necessarily increase the cost of the 
delivery to both the hospital and the patient. 
It must be determined whether it is worth 
the time and expense; and whether it has 
a real value. 

There are many physicians who maintain 
that the suffering of labor is rarely ex- 
cessive; that there is no surgical shock in 

obstetrics; and that since the pain is usually 

87 



NITROUS OXID-OXYGEN ANALGESIA 

forgotten or at least not mentioned after 
the successful termination of labor, it is of 
little importance and may be ignored. But 
believing that the pain of labor is as real 
as is other pain; that women in labor show 
signs of surgical shock; and that it is the 
physician's duty to relieve the suffering of 
the parturient, a careful study of 104 con- 
secutive cases admitted to the maternity 
wards of the Presbyterian Hospital was 
made in order to learn the facts. 

Last April Dr. Grulee, who is in charge 
of the infants, changed the nursing inter- 
vals from three hours to four. It has seemed 
best to study only the cases which have 
been delivered since this change was made 
as the different nursing interval would 
make it difficult to compare the loss in 
weight of the babies had the cases deliv- 
ered prior to this time been considered. 
Furthermore, the technic of administering 
the analgesia has been the same for the 

88 



NITROUS OXID-OXYGEN ANALGESIA 

cases in this series and they have had the 
same postpartum care. During the time 
the patients were in the hospital this paper 
was not contemplated. 

The nitrous oxid-oxygen analgesia was 
administered to all patients who requested 
it, provided they could pay for the gases 
used. We have not been able to furnish 
it to free patients except in certain cases 
where it seemed necessary to make the labor 
as easy as possible. For instance one unfor- 
tunate girl had a mitral stenosis and I 
wanted her to have a labor free from pain 
and muscular effort, so a Voorhees bag 
was inserted and just as soon as the pains 
began, the analgesia was started, and fol- 
lowing the expulsion of the bag the baby 
was delivered with forceps. The results 
in this case were very happy and the 
patient made an uneventful recovery. 

Group I., made up of 50 cases that had 
nitrous oxid analgesia, and 9 cases that had 

89 



NITROUS OXID-OXYGEN ANALGESIA 

the analgesia with ether substituted for the 
delivery. There were in this group 44 
primipara? and 15 multiparas. 

Group II., made up of 45 cases that had 
for the most part no analgesia, some having 
morphin during labor and some ether dur- 
ing the delivery. There were in this group 
18 primiparas and 27 multipara?. 

Table I. Forceps and Pituitrin 

Group I. 

Primiparse : Low forceps were used three 
times; 1, L. O. P. and 2, R. O. P.; pituitrin 
before delivery four times. 

Multipara? : Low forceps were used once 
in a case of mitral stenosis, and pituitrin 
was administered before delivery once. 
Group II. 

Primiparae: Low forceps were used 

twice because of maternal exhaustion, both 

in L. O. A. positions. Pituitrin was used 

once before delivery. 

90 



NITROUS OXID-OXYGEN ANALGESIA 

Multiparas : There were no forceps deliv- 
eries; Voorhees bags were used twice; pitui- 
trin was administered before delivery twice. 

Version was performed once in each 
group, both being for transverse presenta- 
tions. 

Table II. Average Stay in Hospital 

Group I. 

Primiparae: 10.8 days after delivery. 

Multipara* : 11.9 days after delivery. 
Several were in a much weakened condition 
when admitted to the hospital, which made 
the longer stay necessary. 

Group II. 

Primiparse: 12.2 days after delivery. 
This does not include one case that devel- 
oped a puerperal sepsis and remained in 
the hospital 37 days. 

Multiparas: 11.1 days after delivery. 

91 



NITROUS OXID-OXYGEN ANALGESIA 

Table III. Duration of Labor 

Group I. 

Primiparae: Averaged 13.5 hours. 
Multiparas: Averaged 7.33 hours. 

Group II. 

Primiparae: Averaged 17.9 hours. 
Multipara*. Averaged 10 hours. 

Table IV. Weight of Babies at Birth 

Group I. 

Primiparse: Babies averaged 7 lbs. 5 oz. 
(21 males and 23 females). 

Multipara* : Babies averaged 7 lbs. 12 oz. 
(7 males and 8 females). 

Group II. 

Primiparas: Babies averaged 7 lbs. (13 
males and 5 females). 

Multiparas: Babies averaged 7 lbs. 2 oz. 

(12 males and 15 females). 

92 



NITROUS OXID-OXYGEN ANALGESIA 

Table V. Average Loss in Weight 
of Babies 
Group I. 

Primiparse: Babies lost 7.8 oz. or 6.7 
per cent of their body weight, the losses 
ranging from to 16 oz. 

Multiparas : Babies lost 9.4 oz. or 7.58 
per cent of their body weight, the losses 
ranging from 5 to 19 oz. 

Group II. 

Primiparas: Babies lost 7.9 oz. or 7.14 
per cent of their body weight, the losses 
ranging from 4 to 13 oz. 

Multiparas: Babies lost 8.4 oz. or 7.37 
per cent of their body weight, the losses 
ranging from 3 to 14 oz. 

Table VI. Lacerations 

Group I. 

Primiparse: 36 primiparse delivered with 
nitrous oxid-oxygen analgesia had 23 lac- 

93 



NITROUS OXID-OXYGEN ANALGESIA 

erations; 20 slight or first degree, 2 second 
degree, and 1 epesiotomy. 

Eight primiparse with nitrous oxid-oxy- 
gen analgesia during the painful stage with 
ether substituted for delivery had 7 lacera- 
tions; 3 slight or first degree, 3 second 
degree, and 1 epesiotomy. The babies of 
these eight averaged 8 lbs. 

Group II. 

Eighteen primiparse delivered with ether 
or no anesthetic had 14 lacerations; 7 first 
degree and 7 second degree. 

Table VII. Mortality 

Group I. 

There was no maternal or fetal mor- 
tality. 

Group II. 

One primipara with a second degree tear 
developed puerperal sepsis, although she 
did not have a vaginal examination. She 

94 



NITROUS OXID-OXYGEN ANALGESIA 

was in the hospital 37 days but made a 
good recovery. There were three fetal 
deaths; 2 premature babies of about seven 
months, and 1 from injury of the after 
coming head in a breech delivery. 

Table VIII. Postpartum Hemorrhage 

Group I. 

There were no cases of postpartum hem- 
orrhage. 

Group II. 

There was one case of postpartum hemor- 
rhage in a case delivered under ether. 

This series is small but it includes all 
the cases entering the maternity department 
during a period of about four and one-half 
months, except three Cesarean sections 
operated in the gynecological clinic, which 
have no value in this study. The house 
cases all had the same after care, which 

95 



NITROUS OXID-OXYGEN ANALGESIA 

included active and passive exercise, sleep- 
ing on the stomach, backrest during the 
first few days, sitting in a chair on the 
fourth to seventh day, walking a little after 
the sixth or seventh day, and home as soon 
as the patient was strong enough to go 
with perfect safety. But these statistics 
also include a few patients of physicians 
who keep their patients in bed for ten to 
fourteen days. It is also of interest to note 
that these patients seemed weaker after 
the long stay in bed than the other patients 
did after six or seven days. 

From a study of the above tables certain 
facts seem worthy of more than passing 
consideration. A study of larger series 
will undoubtedly alter to some extent 
the percentages here recorded, but from 
our experience we believe that the general 
conclusions will not be materially changed. 

1. A group of 44 primiparas who had 
the nitrous oxid-oxygen analgesia had 

96 



NITROUS OXID-OXYGEN ANALGESIA 

an average labor of 13.5 hours, while 18 
primiparse who had no anesthetic or ether 
during the delivery had an average labor 
of 17.9 hours even though the average 
weight of their babies was five ounces less. 
The 15 multiparas who had the analgesia 
had an average labor of 7.33 hours, and 
the 27 multipara? who had ether or nothing 
had an average labor of 10 hours, yet their 
babies averaged ten ounces less than those 
in the first group. Nor was the duration 
of labor among the unaided cases unusually 
long. "Speigeiberg found in 506 cases the 
average for primipara to be 17 hours and 
for multipara 12 hours." (Webster.) 
Hence it would appear that labor was 
shortened about 25 per cent by the use of 
the nitrous oxid-oxygen analgesia. 

2. Although the patients had the same 
postpartum care and were for the most 
part discharged when strong enough to 
return home with safety, this study shows 

97 



NITROUS OXID-OXYGEN ANALGESIA 

that the 44 primiparae who had the analgesia 
had an average stay in the hospital of 10.8 
days after delivery, whereas the primiparae 
in the other group had an average stay 
of 12.2 days after delivery. The extra 
stay of a day and a half will nearly pay 
for the gas used in the ordinary confine- 
ment. 

3. The use of the nitrous oxid-oxygen 
analgesia does not interfere with the supply 
of milk. The babies of the 44 primiparae 
who had the analgesia lost 6.7 per cent of 
their body weight, while the babies of the 
18 primiparae who were not so fortunate lost 
7.14 per cent of their body weight. Since 
Holt states that the new-born loses an aver- 
age of 11 per cent of its body weight, the 
percentage loss in this series is certainly 
in favor of Dr. Grulee's four hour nursing 
periods. 

4. The use of the nitrous oxid-oxygen 

98 



NITROUS OXID-OXYGEN ANALGESIA 

analgesia by assuring better control of the 
patients, apparently reduces the number 
and severity of the lacerations. 

5. It is not necessary to change from 
the nitrous oxid to ether or chloroform in 
the majority of obstetrical cases. However, 
a hyper-sensitive uterus may necessitate a 
hypodermic injection of morphin or heroin, 
or a change to ether or chloroform to lessen 
the frequency and severity of the uterine 
contractions, but this can be controlled, at 
least in the majority of cases, by adminis- 
tering a nitrous oxid-oxygen anesthesia and 
then returning to a continuous analgesia 
as is employed by dentists. 

6. The use of nitrous oxid does not 
favor postpartum hemorrhage. 

7. The nitrous oxid-oxygen analgesia 
may be used in all types of obstetrics. In 
the normal case and properly administered 
it has a hundred per cent efficency. It may 

99 



NITROUS OXID-OXYGEN ANALGESIA 

be used for versions, forceps, and combined 
with the novocain infiltration for Cesarean 
sections. 

The use of the nitrous oxid-oxygen 
analgesia will rob labor of its greatest 
terror. 



100 



CHAPTER XI 

Technic of Administering Nitrous 

Oxid-Oxygen Analgesia 

In Normal Obstetrics 

The first consideration in the use of 
nitrous oxid and oxygen is the choice of a 
gas machine. While any gas machine may 
be used, from our experience we would 
make the following suggestions: (1) The 
apparatus should be a nitrous oxid-oxygen 
mixer, as the use of straight nitrous oxid 
has marked limitations. (2) It should have 
some type of automatic regulators which 
will maintain a relatively constant pressure 
in the gas bags. (3) The mixture of the 
gases should be controlled by a single valve 
or lever. (4) Portability is desirable but 
is secondary to usefulness and durability. 

101 



NITROUS OXID-OXYGEN ANALGESIA 

The nitrous oxid-oxygen analgesia as 
used in obstetrics is similar to that used 
extensively by dentists, but differs in that 
it is not administered continuously. The 
technic which I will describe is used with 
minor variations by the Obstetrical Staff of 
the Presbyterian Hospital, Chicago. I 
believe, with Dr. F. W. Lynch, that a 
physician will best use this method after 
carefully testing the effects of nitrous oxid 
and oxygen on himself. 

In administering the analgesia, economy 
is desirable and may be secured in the 
following ways: (1) Be certain that there 
is no leakage of gas from the tops of the 
cylinders or from any of the connections. 
(2) Never more than half fill the gas bags 
and usually keep them about one-third dis- 
tended. (3) Use the minimum number of 
regular deep inhalations necessary to secure 
the analgesia. (4) Do not anesthetise the 
patient. (5) Use the large cylinders of 

102 



NITROUS OXID-OXYGEN ANALGESIA 

nitrous oxid and oxygen in hospital prac- 
tice. 

The automatic regulators on the appa- 
ratus we use (the Clark) are set at a point 
which allows the bags to become about one- 
third distended when the gases are turned 
on. In case such regulators are not used 
the bags should be half filled between 
uterine contractions. For the women who 
will cooperate with the physician, the nasal 
inhaler is the better; but for mouth 
breathers, hysterical women, and those who 
will not follow instructions, the face inhaler 
is necessary. 

On admission to the hospital the patient 
has the usual preparation for delivery. She 
is told that the nitrous oxid will be given 
just as soon as her contractions begin to 
hurt. Generally the patient will not ask 
for the analgesia until the cervix is fairly 
well dilated and the uterine contractions 
coming every few minutes. She is then 

103 



NITROUS OXID-OXYGEN ANALGESIA 

placed on the delivery bed and taught how 
to breathe the gases, and, if the labor is 
well advanced, how to work. This is at 
times difficult, but is usually accomplished 
during the first few contractions. It is 
advisable to have the room slightly darkened 
and free from unnecessary noise and con- 
versation. Cold compresses on the forehead 
covering the eyes are soothing. 

With the first suggestion of a uterine con- 
traction, the inhaler is placed in position 
quickly as the release valve is opened. The 
patient is given two deep inhalations of 
pure nitrous oxid; four per cent oxygen is 
given with the third inhalation and from 
six to twenty per cent is given subsequently. 
The percentages must be determined for 
each patient. If the labor is well advanced 
the patient is instructed to hold her breath 
and bear down after the fourth or fifth 
inhalation. However, if it is found that 
two or three inhalations will produce the 

104 



NITROUS OXID-OXYGEN ANALGESIA 

analgesia, she should bear down as soon as 
the analgesia is assured. She is then given 
another inhalation and again may bear 
down. The valve is now closed to prevent 
further escape of the gases, but instead of 
removing the inhaler the lower edge is 
raised sufficiently to permit the breathing 
of air, and is removed only at the end of 
the contraction. The patient is then told 
to lie quietly and rest until the next con- 
traction. 

It is advisable that the physician follow 
the progress of labor by means of rectal 
examinations. A vaginal examination is 
rarely necessary in a normal case, and 
should not be made unless there is a fairly 
definite indication. Unless the physician 
is alert, the patient, especially if she is 
a multipara, may precipitate. Although 
the analgesia has no appreciable effect on 
the fetus, the fetal heart rate should be 
followed with the usual care. 

105 



NITROUS OXID-OXYGEN ANALGESIA 

During analgesia the patient holds the 
straps which are fastened to the foot of 
the bed and makes traction on them during 
the bearing down efforts of the second 
stage. When the caput appears at the 
vulva the patient is warned that she must 
immediately obey every instruction, and she 
bears down or does not at the request of 
the obstetrician. More nitrous oxid is often 
required during the delivery of the head, 
but the patient should not become anes- 
thetised as she will then lose her self-control 
and may struggle as with ether. 

If the child should be somewhat cyanotic 
because of prolonged birth pressure or from 
the cord being tightly around the neck, the 
mother may be given pure oxygen so long 
as the cord pulsates, and the oxygen may 
then be administered to the child. 

The nurse or some member of the family 
may be taught to administer the analgesia 
for the normal obstetrical case. Nitrous 

106 



NITROUS OXID-OXYGEN ANALGESIA 

oxid can only cause death from asphyxia, 
and in giving the analgesia this is impossible 
owing to the use of oxygen and the few 
inhalations required. However, a nitrous 
oxid anesthesia is difficult to administer and 
should be undertaken only by the expert. 

Self Administration or Nitrous Oxid- 
Oxygen Analgesia 

One of the chief objections to the admin- 
istration of the nitrous oxid-oxygen anal- 
gesia is the necessity of remaining con- 
stantly with the patient. For some time 
the Clark engineers have experimented 
with various suggestions to overcome this 
objection. They now have a little trigger 
valve which is attached next to the inhaler 
and since the gas machine is equipped with 
automatic regulators the patient may ad- 
minister with safety her own analgesia dur- 
ing the earlier stages of labor, thus doing 
away with the necessity of a constant 

107 



NITROUS OXID-OXYGEN ANALGESIA 

attendant. There can be no danger to the 
patient since if she should take enough gas 
to carry her to the stage of anesthesia her 
fingers would relax, the valve close and 
the inhaler fall away. 

In using the self administration several 
points must be borne in mind. The patient 
must first be taught to understand what 
is meant by analgesia. She must learn that 
a few inhalations will deaden the pain and 
that to use more than the minimum number 
is to waste gas and increase the cost of 
administration. She should never make 
any bearing down efforts except at the 
direction of the physician. Since the use 
of the nitrous oxid and oxygen relieves the 
pain the stage of labor cannot be judged 
by the loudness of the patient's outcries. 
Patients may precipitate while under the 
analgesia without knowing that the baby is 
being born. With a multipara it is usually 
wise for the physician to stay near the 

108 



NITROUS OXID-OXYGEN ANALGESIA 

patient from the beginning of the bearing 
down pains. While self administration is 
practical and may be used successfully, the 
nurse or the physician should always be 
near at hand and closely follow the prog- 
ress of the labor. 

Nitrous Oxid and Oxygen in Operative 

Obstetrics 

Dr. J. C. Webster during the past ten 
years has thoroughly demonstrated that 
nitrous oxid-oxygen anesthesia is practical 
for all types of operative obstetrics. I have 
administered this anesthetic for many ob- 
stetrical operations, and, during the past 
few years, have performed several versions 
and instrumental deliveries with this anes- 
thesia; but from the experience of the past 
few months I believe that it is easier to 
operate with a fairly deep analgesia, as the 
patient understands what is being done and 
said, and is less apt to struggle. 

109 



NITROUS OXID-OXYGEN ANALGESIA 

In many cases it will be advisable to use 
a little ether with the nitrous oxid-oxygen, 
especially if the anesthetist has had but 
little experience. 

The ideal anesthesia for Cesarean section 
is a combination of the nitrous oxid-oxygen 
analgesia with the local infiltration of the 
skin, superficial fascia and parietal perito- 
neum with novocain (1 to 100). The open- 
ing of the uterus does not cause pain, unless 
traction is made on the broad ligaments, 
and therefore requires no anesthetic. By 
injecting an ampule of pituitrin into the 
uterine wall, as is done by Dr. Webster, 
and leaving the uterus in the abdominal 
cavity there is very little blood lost. I first 
gave the nitrous oxid-oxygen analgesia 
combined with the novocain infiltration in 
a case Dr. Webster operated in April, 1915. 
Since then I have administered it several 
times and in July performed a Cesarean 

110 



NITROUS OXID-OXYGEN ANALGESIA 

section under this anesthesia. The results 
have been most satisfactory. The patients 
hear everything that is said but do not 
suffer mentally as when the operation is 
performed under the local anesthesia alone. 
In administering the continuous analgesia 
for operative obstetrics the gas bags should 
be half distended and at times it is neces- 
sary to have them two-thirds distended. 
The mixture of the gases should contain 
from ten to twenty per cent of oxygen. 
It is usually advisable to talk to the patient, 
reassuring her and telling her to breathe 
naturally. If at any time she complains 
of pain she should be given a few deep 
inhalations containing a smaller percentage 
of oxygen. Try to maintain a deep 
analgesia in which the patient can hear 
and understand everything, yet so near 
anesthesia that she shows lack of coordina- 
tion in her answers to questions. 

Ill 



NITROUS OXID-OXYGEN ANALGESIA 

Rebreathing in Nitrous Oxid-Oxygen 

Analgesia 

Rebreathing may be practiced to some 
extent in the nitrous oxid-oxygen analgesia. 
The use of rebreathing in the normal labor 
case will reduce the cost of gas about fifty 
per cent, but if it is continued over a long 
period, the patient may complain of symp- 
toms similar to those produced by sleeping 
in a stuffy room. She is apt to have a 
headache and complain of a bad taste in 
the mouth. If rebreathing is practiced it 
is advisable to give the patient pure oxygen 
for several minutes after the termination 
of labor. 

Use of Narcotics with Nitrous Oxid- 
Oxygen Analgesia 

A long first stage of labor is fatiguing 
and at times somewhat painful. The 
uterine contractions are in some cases so 

112 



NITROUS OXID-OXYGEN ANALGESIA 

frequent and strong that sleep becomes 
impossible and unless care is used the 
patient may become exhausted and very- 
nervous before reaching the expulsive con- 
tractions of the second stage. In this type 
of cases we have been accustomed to give a 
hypodermic injection of morphin sulphate 
grs. 1/6, or heroin hydrochlorid grs. 1/12, 
either alone or with chloral hydrate grs. x 
to xx per rectum. 



113 



CHAPTER XII 

Reasons for Failures in Securing 
Analgesia 

Failures are comparatively rare in the 
use of nitrous oxid-oxygen analgesia, but 
I know of one case where there was appar- 
ently very little benefit derived from the 
use of the gas and it was considered neces- 
sary to change to ether to lessen the severity 
of the pains during the delivery. Since I 
had never had this experience, I questioned 
this patient closely to determine the cause 
of the failure. She stated that the pains 
came on very quickly; that they were 
usually intense before she had her first 
inhalation of the gas; and that she did 
not feel any effect from the gas until after 
the contraction was over. 

The physician stated that she had an 

114 



NITROUS OXID-OXYGEN ANALGESIA 

unusually irritable uterus and that the con- 
tractions were very severe. The intern was 
probably a little slow in administering the 
gas. 

Since the patient did feel some analgesic 
effect following the contraction the failure 
was not due to a lack of susceptibility to 
the nitrous oxid, and it seems probable that 
had the gas been administered earlier before 
the painful stage of the contraction that 
the results would have been different. 
Recently Dr. Webster had a similar case, 
but we gave the patient complete relief( 
from pain by administering a continuous 
analgesia for nearly three hours. 

In describing the technic, I called atten- 
tion to the need of quickness in the admin- 
istration of the gas. One must work with 
both hands so rapidly that the patient will 
get the nitrous oxid with the first inhalation 
she takes after there is the first suggestion 
of a contraction coming. Analgesia must 

115 



NITROUS OXID-OXYGEN ANALGESIA 

be assured before the height of the con- 
traction, or painful stage, is reached. 

However, there are cases in which the 
extreme irritability of the uterus may be- 
come a source of danger to both the mother 
and the fetus. It is possible that nitrous 
oxid, which seems to stimulate the uterine 
contractions, may be contraindicated in this 
event. In the past it has been the practice 
of most obstetricians to control these cases 
with small doses of morphin, and if neces- 
sary the morphin may be given during the 
analgesia. Whether it would be advisable 
to change to ether or chloroform, can only 
be determined from the combined experi- 
ences of many observers. 

In cases with an irritable uterus and very 
frequent violent contractions, I would 
advise the administration of a continuous 
analgesia and if there was still difficulty 
in controlling the pain the patient may be 
given anesthesia during the contractions. 

116 



NITROUS OXID-OXYGEN ANALGESIA 

At present I do not believe that it is neces- 
sary to change to 'ether or chloroform for 
any normal delivery. There are many 
operative cases where the ether may be the 
better anesthetic, but this depends largely 
on the operator and the ability of the 
anesthetist. 



117 



CHAPTER XIII 

Nitrous Oxid- Air or Nitrous Oxid- 

OXYGEN 

A satisfactory analgesia, in most cases, 
can be obtained with nitrous oxid and air 
as has been advocated by Guedel. We have 
used this method with very good results; 
but it must be remembered that in giving 
20 per cent air we are supplying 16 per 
cent nitrogen for 4 per cent oxygen. Since 
nitrogen is an inert gas its presence retards, 
rather than aids, in the securing of anal- 
gesia. It would seem more logical to use 
pure nitrous oxid and give one less inhala- 
tion. Four inhalations of pure nitrous oxid 
will apparently equal in efficiency five 
inhalations containing 20 per cent air, and 
since there is no danger from asphyxia in 
taking five or six inhalations of pure gas I 

118 



NITROUS OXID-OXYGEN ANALGESIA 

can see no logical reason for using the air. 

In our work we give two deep inhalations 
of pure nitrous oxid, adding the oxygen in 
the later inhalations. Our purpose is to 
secure analgesia as quickly as possible, yet 
adding the oxygen to prevent the slight 
headache which may come from the use 
of pure nitrous oxid. 

While we desire to prevent the possible 
occurrence of a headache, there is a more 
important reason for using a nitrous oxid- 
oxygen apparatus and always planning to 
have a supply of oxygen. We have all seen 
cases in which the labor was severe and 
tedious, when because of marked birth pres- 
sure or a cord tightly wound about the 
neck, the resuscitation of the child has been 
very difficult and at times impossible. 
Various life-saving devices, such as lung- 
motors and pulmotors, have been used suc- 
cessfully in some of these cases. Artificial 
respiration will usually prove sufficient, 

119 



NITROUS OXID-OXYGEN ANALGESIA 

especially if the baby is given pure oxygen. 
In reviewing the records of Mr. A. C. 
Clark's daughter, I find that she was given 
pure oxygen so that the blood of the child 
6ould be oxygenated through the blood of 
the mother. It is stated that the cyanosis 
disappeared in a comparatively short time. 
I administered pure oxygen to the mother 
of one blue baby until the cord stopped 
pulsating with gratifying results. The oxy- 
gen tube was later held over the baby's 
mouth. If we can save one baby in a 
thousand by having a supply of oxygen, 
surely it is worth carrying it. 



120 



CHAPTER XIV 

A COMPARATIVE STUDY OF 154 CONSECUTIVE 

DELIVERIES AT THE PRESBYTERIAN 

HOSPITAL, CHICAGO 

{Presented to the Chicago Gynecological 
Society, Nov. 19, 1915.) 

The use of nitrous oxid and oxygen in 
the obstetrical work at the Presbyterian 
Hospital began about eleven years ago. 
Dr. Webster first used the nitrous oxid- 
oxygen anesthesia in operative obstetrics 
when ether and chloroform were contra- 
indicated. Its use was gradually extended 
to all types of cases, but prior to 1913 it 
was restricted to private patients and in no 
case was it used longer than two hours. 
During the winter of 1913 Drs. Lynch and 
Heaney experimented with the nitrous oxid- 

121 



NITROUS OXID-OXYGEN ANALGESIA 

oxygen analgesia using it during the entire 
painful stage of labor in quite a number of 
cases. The various members of the staff 
experimented with the method during the 
winter of 1914, and after we were all con- 
vinced that it was safe, practical and not too 
expensive, Dr. Webster reported it to the 
Chicago Gynecological Society. 

During the past seven months the technic 
employed has been practically the same, the 
postpartum care has varied very little, and 
the infants have been on the four hour nurs- 
ing intervals. For these reasons it has 
seemed best to study only the cases deliv- 
ered during this period. In September, I 
tabulated 104 cases delivered during the 
previous four and one-half months. The 
analgesia was administered to all patients 
who requested it provided they could pay 
its cost, and to a few charity cases whose 
physical condition made an easy labor nec- 
essary. There were in this series 44 primi- 

122 



NITROUS OXID-OXYGEN ANALGESIA 

para* and 15 multiparas who had the nitrous 
oxid-oxygen analgesia, and 18 primiparae 
and 27 multiparas who had nothing, or ether 
for delivery. Since making this study 53 
more cases have been discharged from the 
maternity department and 50 of these had 
nitrous oxid and oxygen during a part or 
all of the painful stage of labor, the periods 
ranging from fifteen minutes to seven hours. 
There were in this second group 23 primi- 
paras and 27 multiparas. The table on page 
124 shows the comparative findings of the 
two studies, and is of considerable interest 
in that the first were more or less selected 
while the second group of analgesia cases 
were consecutive. 

The statistics recorded in this table speak 
for themselves and while I must confess 
that the results were more favorable than 
any of us had expected, they substantiate 
all of the claims made for the nitrous oxid- 
oxygen analgesia, and I believe that within 

123 



NITROUS OXID-OXYGEN ANALGESIA 



Deliveries 


Nitrous Oxid-Oxygen 
Analgesia 


No 
Analgesia 


April to Novem- 


Series I 


Series II 


Series I 


ber, 1915 


44 
prim. 


15 

mill t. 


23 
prim. 


27 
mult. 


18 
prim. 


27 
mult. 


Av. dur. labor 


13.5 
hrs. 


7.33 
hrs. 


11.25 
hrs. 


6 hrs. 


17.9 
hrs. 


10 
hrs. 


Sex of infant 


21 
male 

23 
female 


7 

male 

8 

female 


11 
male 

12 
female 


13 
male 

14 
female 


13 

male 

5 
female 


12 
male 

15 
female 


Av. wt. at birth. . . 


7 lb. 
5 oz. 


7 lb. 
12 oz. 


7 lb. 
6 oz. 


7 lb. 
7 oz. 


7 lb. 


7 lb. 
2 oz. 


Av. loss in wt. aft- 
er birth. First 
week 


7.8 oz. 


9.1 oz. 


8 oz. 


8.63 
oz. 


7.9 oz. 


8.4 oz. 


Percentage of wt. 
lost. First week. 


6.7% 


7.58% 


6.8% 


7.25% 


7.14% 


7.37% 


Voorhees bag 








1 


4 








Pituitrin before de- 
livery 


4 


1 


3 


1 


1 


2 


Forceps delivery. . . 


1 
L.O.P. 

2 
R.O.P. 


1 mi- 
tral 
ste- 
nosis 


1 mi- 
tral 
ste- 
nosis. 
1 no 
prog- 
ress 
3 hrs. 

7 
6 

3 


1 high 
R.O.P. 

2 deep 
R.O.T. 


2 
L.O.A. 
ma- 
ternal 
exh'n 





Lacerations : 

First degree 

Second degree. . . 
Third degree. . . . 
Epesiotomies . . . 


23 
5 

2 


3 
4 




2 
4 




7 
7 




5 

2 




Maternal deaths . . . 




















Still-births 








1 (a) 











Died first week .... 








1 (b) 





2 (c) 


1 (d) 


Post-partum hem. . 

















1 


Failure to secrete 
milk 




















Days in hospital 
after delivery. . . . 


10.8 


11.9 


11.7 


10.7 


12.2 


11.1 



(a) Patient admitted to maternity 30 minutes before de- 
livery, had not felt life since labor began. Only had N20-0 
less than 20 minutes. 

(b) Died 12 hrs. after birth. Necropsy showed patent 
foramen ovale. 

(c) One premature 6^ mo. One injury in delivery of the 
after-coming head in a breech presentation. Necropsy 
showed rupture of the longitudinal sinus. 

(d) Case of hydramnios with premature delivery at 6 
months. 

From the clinic of Dr. J. Clarence Webster, Presbyterian 
Hospital, Chicago. 

124 



NITROUS OXID-OXYGEN ANALGESIA 

the year these results will be confirmed by 
obstetricians in all parts of the country. 

In administering the nitrous oxid-oxygen 
analgesia there are several points which 
deserve special attention. It must be 
remembered that nitrous oxid anesthesia 
cannot be given according to ether stand- 
ards or rules, and furthermore, that nitrous 
oxid-oxygen analgesia differs from both. 
In administering the obstetrical analgesia 
the patient will never become cyanotic 
since this can only follow anesthesia and is 
the first symptom of asphyxiation. With 
our present technic there is little chance of 
anesthetising the patient since we determine 
the minimum number of regular deep inhal- 
ations required to produce analgesia and 
when these are given the valve is closed and 
the edge of the inhaler is raised sufficiently 
to permit the breathing of air. As the 
contractions increase in duration and sever- 
ity one or more inhalations is added, but it 

125 



NITROUS OXID-OXYGEN ANALGESIA 

is rarely necessary to continue the gas to 
the end of the contraction. In case the 
uterus is very irritable and the contractions 
come on so quickly that the patient feels 
severe pain before the analgesia can be 
secured it may be necessary to administer 
a continuous analgesia, but again there is 
no danger of anesthesia or cyanosis if fifteen 
or twenty per cent of oxygen is added. In 
a case that Dr. Webster confined recently, 
using the usual technic we were unable to 
relieve the suffering, but this was overcome 
by administering a continuous analgesia for 
nearly three hours. Thus far I have not 
had a case in which it was not possible to 
relieve the suffering of labor by means of 
the nitrous oxid-oxygen analgesia, and I 
have used it in all types of cases and all 
classes of patients. Patients who refused 
to take anything have been forced to take 
the gas as a means of securing quiet in the 
maternity, patients who understood no 

126 



NITROUS OXID-OXYGEN ANALGESIA 

English or German have been taught to 
take the analgesia with very little difficulty, 
and within a few contractions. 

The administration of the nitrous oxid- 
oxygen analgesia, or in fact that of any 
form of analgesia has required a constant 
attendance on the patient which is very tire- 
some and at times quite difficult. The self- 
administration of chloroform a la reine has 
long been practiced in certain parts of 
Europe, and it has seemed that a similar 
method might be practical with the nitrous 
oxid. After several conferences with the 
engineering department of the A. C. Clark 
Co., they have perfected a release valve 
which is attached near the inhaler by means 
of which it is practical for the patient to 
administer her own analgesia during the 
greater part if not all of the painful part 
of labor. This valve serves a double pur- 
pose in that it prevents the mixture of air 
with the gas in the tube during the intervals 

127 



NITROUS OXID-OXYGEN ANALGESIA 

between pains. In using the self adminis- 
tration I would suggest that the mixture 
contain about five per cent oxygen, and that 
the mixing valve need not be changed 
except in case a different percentage of 
oxygen is desired. Should the patient not 
follow instructions and take more than the 
required number of inhalations she can do 
no real harm since if she should become 
anesthetised her fingers would relax, the 
inhaler fall away and the spring exhaust 
valve automatically close. 

Nitrous oxid-oxygen analgesia in obstet- 
rics has passed the experimental stage and 
is now practical in all classes of cases. In 
the practice of every physician who under- 
stands the science of obstetrics it is an abso- 
lutely safe and comparatively simple 
method of eliminating the suffering and 
shock of labor. When it is used the delivery 
room is as quiet as any other operating 
room. However, with the analgesia the 

128 



NITROUS OXID-OXYGEN ANALGESIA 

stage of labor cannot be judged by the 
nature of the outcry and the obstetrician 
must carefully watch his patient or she will 
deliver her baby and not know that it is 
being born. 



129 



CHAPTER XV 

Conclusions 

Experience with all types of cases, all 
classes of patients, and the various forms 
of obstetrical analgesia has led to the fol- 
lowing general conclusions: 

1. The pain of labor is as real as is 
any other pain and should be relieved. 
Childbirth may be made relatively free from 
suffering. 

2. Obstetrical analgesia is a conservative 
measure. 

3. While most of the drugs used in 
securing obstetrical analgesia have serious 
limitations and several contraindications, the 
nitrous oxid-oxygen analgesia may be used 
in practically all classes of cases. It has 
no contraindications other than a threatened 

130 



NITROUS OXID-OXYGEN ANALGESIA 

rupture of the uterus and then morphin is 
the analgesic of choice. 

4. Morphin, heroin, chloral hydrate or 
scopolamin, may be used to rest the patient 
in the event of a prolonged first stage of 
labor. 

5. When there is a premature rupture 
of the membranes, with the cervix not 
effaced, some type of rubber bag should 
be inserted to aid in the dilatation of the 
cervix. The analgesia may be started just 
as soon as the patient complains of pain. A 
small dose of pituitrin after the expulsion of 
the bag will prevent secondary inertia. 

6. Any form of obstetrical analgesia, 
properly administered, is safer and better 
for the patient than no analgesia. 

7. The nitrous oxid-oocygen analgesia is 
absolutely safe in the hands of any physi- 
cian who understands the practice of obstet- 
rics, and properly administered will relieve 
the suffering in every case in which it is 

131 



NITROUS OXID-OXYGEN ANALGESIA 

used. The pain may not be entirely de- 
stroyed in every case but is materially 
reduced and made bearable. 

8. Women who have the analgesia dur- 
ing the painful stage of labor have shorter 
labors and do better afterwards than do 
those who have no analgesia or ether just 
for the delivery. 

9. From a study of 154 consecutive 
cases entering the maternity wards of the 
Presbyterian Hospital, Chicago, it would 
seem that the use of the nitrous oxid-oxygen 
analgesia reduces the duration of labor 25 
per cent. 

10. The use of the nitrous oxid-oxygen 
analgesia does not interfere with the supply 
of milk, but, by lessening the shock, favors 
the secretion of milk. 

11. The use of the nitrous oxid-oxygen 
analgesia in the cases studied decreased the 
number and severity of the lacerations. 

12. The nitrous oxid-oxygen may be 

132 



NITROUS OXID-OXYGEN ANALGESIA 

used for all types of operative obstetrics, 
and it is rarely necessary to resort to ether 
or chloroform. 

13. While the cost of labor is slightly 
increased from the use of the nitrous oxid- 
oxygen analgesia, the cost is insignificant 
when compared to the relief of suffering. 
The cost of the gases used in the ordinary 
obstetrical case varies from fifty cents to 
one dollar per hour. 

14. The nitrous oxid-oxygen analgesia 
may be administered in the home as well 
as the hospital and by every physican who 
practices obstetrics. 

15. The use of the nitrous oxid-oxygen 
analgesia will rob labor of its greatest ter- 
ror. It is both sane and safe, and is a 
logical method of relieving the suffering 
during childbirth. 

16. Eutocia must be the aim. Nitrous 
oxid-oxygen analgesia should be a blessing 
to mothers, but it may however be converted 

133 



NITROUS OXID-OXYGEN ANALGESIA 

into little else than a curse, unless people 
are educated to the need of better obstet- 
rics and the average methods employed in 
obstetrical practice are improved. 



134 



YOUR BABY 

A Guide for Mothers 

BY DR. E. B. LOWRY 

This book contains the latest and best ap- 
proved methods for the care of the mother 
and baby. It is a strong plea for better 
babies and every doctor will welcome the 
circulation of this great help to mothers. 

"This book can be safely and heartily recommended to 
every prospective mother." — The Chicago Medical Recorder. 

"The directions are clear and the advice is sensible." — 
New York Sun. 

"This helpful book is in keeping with Dr. Lowry's pre- 
viously published meritorious works." — The Southern Clinic. 

"A safe, sane and interesting book which it would be 
well for every young woman to read. It deserves a wide 
circulation." — The Wisconsin Medical Journal. 

"A valuable handbook of approved medical rules and 
common-sense help for mothers." — Kansas City Star. 

"This book is an education of which every prospective 
mother, in justice to her child, ought to give herself the 
benefit." — Harrisburg Telegraph. 

"The book is practical, lucid, helpful. The writer of the 
book is an authority on the subject and has the gift of 
stating facts with unmistakable clearness." — San Francisco 
Call. 

Cloth bound. 256 pages. 

PRICE $1.00 

For sale wherever books are sold or supplied by the publishers 

Forbes & Co., 443 S. Dearborn Street, Chicago 



HERSELF 

Talks with Women Concerning Themselves 

BY DR. E. B. LOWRY 

This notable book on sexual hygiene contains full 
and precise and straightforward as well as trust- 
worthy information on every question of import- 
ance to women concerning their physical nature. 

Dr. Lowry is famous as the author of the only 
books on sexual hygiene which have received the 
unanimous endorsement of the leading medical and 
educational authorities. 

"Should be recommended by physicians to all their female 
patients." — The Lancet-Clinic. 

"Dr. Lowry's books are excellent and can be safely recom- 
mended." — The Journal of the American Medical Associa- 
tion. 

"A very excellent book that will save many from physical 
and mental suffering." — Iowa Medical Journal. 

PRICE $1.00 



THE HOME NURSE 

BY DR. E. B. LOWRY 

This very useful book gives helpful directions for 
the care of the sick in the home and tells how to co- 
operate with the physician in providing for the 
comfort and cure of invalids. 

"A sensible book, and it should be in every home book- 
shelf." — Northwest Medicine, Seattle. 

"It serves a very useful purpose and is readily under- 
stood. Physicians will welcome the circulation of this ex- 
cellent book." — Medical Sentinel, Portland, Ore. 

PRICE $1.00 
Forbes & Co., 443 S. Dearborn Street, Chicago 



